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tihr<ivy  of  t:he  theological  ^tminary 

PRINCETON  .  NEW  JERSEY 

FROM  THE  LIBRARY  OF 
ROBERT  ELLIOTT  SPEER 


BV  3415  .L45 

Lennox,  William  Gordon,  188 


—  The  health  of  missionary 


rOTAL    HOMbtR.    DCATHJ    PER    looo    LIVIMO     BIRTHS 


7B  AND    74  TO    101'  rO     I'ZU  TD    ISI  TO    1/4  TO    20I  AND 
BELON    too       125  ISO         I7B        200         OVER. 


Frontispiece.  Mortality  of  missionary  children  by  provinces.  (Illustrating 
Table  25.)  The  more  heavily  shaded  the  province,  the  higher  is  its 
mortality  rate.  The  figui-es  under  the  name  of  the  province  indicate  the 
number  of  children  dead  (of  all  ages)  per  1,000  living  births.  The  heavy 
lines  mark  the  division  into  North,  Central,  and  South  China  used  in 
this  study.  Honan  is  included  in  Central  China.  Absence  of  boundary 
lines  between  provinces  means  that  in  the  tabulations  these  provinces  are 
grouped  together.  . 


THE  HEALTH  OF  MISSIONARY 
FAMILIES  IN  CHINA 

A  Statistical  Study 


/     By 

Wm.  G.  Lennox,  M.  D. 


Department  of  Economics 

University  of  Denver 


DENVER,  COLO. 

U.S.A. 


o^ 


Acknowledgment 

The  writer  wishes  to  acknowledge  the  assistance  given  by 
the  many  missionaries  who  spent  much  time  and  thought  in 
giving  of  their  experiences  and  advice.  Special  thanks  are 
due  to  Dr.  H.  S.  Houghton,  through  whom  the  Peking  Union 
Medical  College  made  a  contribution  of  Mex  $300,  toward  the 
expenses  of  the  study;  to  Rev.  C.  L.  Boynton,  editor  of  the 
China  Missionary  directory;  to  Professor  G.  A.  Warfield,  of 
the  University  of  Denver,  to  various  mission  board  officers 
who  have  manifested  an  interest  in  this  study,  and  to  the 
students,  both  Chinese  and  American,  who  have  assisted  in 
the  task  of  tabulation. 


Contents 

PART  I.     The  Health  of  the  Childbeit 


P»!te 

Introduction    9 

The  Value  of  Child  Life  to  Missions 10 

What  This  Study  Hopes  to  Do 10 

Method  of  Collecting  Data 11 

General  Facts  Concerning  Data 12 

The  Number  of  Children 14 

Children  per  Marriage 14 

Childless  Marriages 17 

Size  of  Families 18 

Ages  and  Years  in  China 20 

Masculinity  23 

Conditions  Affecting  Children 23 

Comparative   Mortality 24 

Missionaries   and  Chinese 24 

Missionaries  in  China  and  Japan 25 

Infant  Mortality 26 

Mortality  in  Early  Childhood 28 

Factors  in  Child  Mortality 30 

Geographical  Location 31 

Missionary    Societies 33 

Societies  in  Relation  to  Location 37 

Size  of  Societies 40 

Nationality  of  Societies 40 

Birthplace  of  Parents 41 

Medical  Training  of  Parents 43 

Ratio  of  Doctors  to  Mission  Force 40 

Recent  and  Remote  Periods 47 

Order   of   Birth 50 

Number  of  Children  in  Family 51 

Birthplace  of  Children 52 

Other  Factors  of  Child  Mortality 52 

Cause  of  Deaths  by  Groups  of  Diseases 54 

Geographical    Location 54 

Missionary    Societies 55 

Nationality  of  Societies 58 

Birthplace  of  Parents 59 

Medical  Training  of  Parents 59 

Recent  and  Remote  Periods 60 

Order  of  Birth 61 

Number  of  Children  in  Family 63 

3 


CoNTEN  TS — Continued 

Page 

Causes  of  Deaths  by  Individual  Diseases 64 

Deaths  Outside  China 69 

Morbidity  Among  Children 70 

Percentage  of  Mortality 75 

Major  and  Minor  Infections 7G 

Geographical  Location 77 

Missionary    Societies 77 

Age  at  Time  of  Sickness 78 

Mortality  Rate  in  Relation  to  Age 79 

General   Health  of  Children 79 

Geographical    Location 79 

Missionary    Societies 80 

Miscarriages  and  Stillbirths 81 

Geographical  Location 82 

Missionary    Societies 84 

Causes  of  Miscarriages 84 

Conditions  Other  Than  Health 86 


PART  II.     Health  of  Married  Adults 

Introduction    87 

Facts  Concerning  Residence  and  Marriage 88 

Mortality  Among  Adults 91 

Morbidity  Among  Adults 91 

Geographical  Location 92 

Period  When  Sicknesses  Are  Contracted 96 

Proportion  Without  Serious  Sickness 97 

Past  General  Health 98 

Geographical  Location 98 

Missionary    Societies 99 

PART  III.     Some  Factors  in  Prevention  of  Disease 

The  Preventable  Diseases 100 

Dysentery    100 

Typhoid    Fever 101 

Smallpox    102 

Causes  of  Infection 105 

Methods  of  Disease  Prevention 106 

The  Responsible  Agencies 110 

The  Extravagance  of  Sickness 114 

Summary 115 

References  120 

4 


Tables  and  Chaets 

Tables  are  illustrated  in  whole  or  in  part  by  the  Figures  whose  numbers 

ARE   indicated. 

Table      Figure 

Nuiuber  Number  Page 

1  Percentage  answering  questionnaire  by  provinces 13 

2  Percentage  answering  questionnaire  by  societies 13 

3  Number  of  children  born,  now  living  and  now  dead,  per  family 

of  missionaries,  by  years  of  marriage 14 

4  Size  of  families  of  faculty  members  of  American  universities.  .  14 

5  Number  of  children  per  family  for  various  groups  in  compari- 
son with  missionary  families 15 

6  Number  of  married  years  per  living  birth  by  groups  of  societies  15 

7  12     Number  of  children  per  family  by  societies 16,  35 

8  Number   of  children   per   family,   and    percentage   of   families 
without  children,  by  groups  of  societies  of  various  nations. ...   16 

9  Percentage  of  families  with  specified  number  of  children  born, 
by  years  of  parents'  marriage 18 

10  Size  of  families  of  American  college  teachers,  of  women  col- 
lege graduates  and  of  missionaries 18 

11  Percentage  of  families  with  specified  number  of  children  now 
living,  by  years  of  parents'  marriage 19 

12  Percentage  of  families  with  specified  number  of  children  now 
dead,  by  years  of  parents'  marriage 19 

13  Percentage  of  families  with  specified  number  of  children  dead, 
by  societies  19 

14  Children — percentage  of  years  in  China,  by  provinces 20 

15  12     Number  of  years  of  life  of  children,  and  years  spent  in  China, 

by    societies    21 

16  Number  of  children  alive,  by  age  and  province 22 

17  Relation  of  male  to  female  births,  by  groups  of  provinces 23 

18  1     Mortality  among  children  of  missionaries  and  of  lower  class 

Chinese 24 

19  2     Mortality  of  missionary  children  in  China  and  in  Japan 25 

20  Percentage  of  infant  deaths  occurring  by  months,  for  United 
States  and  various  classes  of  English  society,  and  for  mis- 
sionary children    26 

21  3     Infant  mortality  occurring  by  months  for  two  classes  of  Eng- 

lish society,  and  for  missionary  children 27 

22  4-5     Mortality  for  the  first  ten  years   among  missionary  children 

and  among  children  in  America  and  England 28 

23  6     Child   and   infant  mortality   in   city   and   country   districts   of 

England  compared  with  those  of  missionary  children 29 

24  7     Percentage  of  children  dying,  and  percentage  now  living,  at 

various  ages   30 

25  8-9-10     Mortality  of  children  by  provinces,  arranged  by  geographical 

Frontispiece  SectlonS    31,    32,    33 

26  11-12     Mortality  of  children,  by  societies 34,  35 

27  Mortality  of  children   in   societies   reporting  between   20   and 

75  children    37 

28  Percentage  of  children  living  in  sections  of  China,  by  societies.  37 

29  Mortality  of  children  by  societies,  and  by  sections  of  China 39 

5 


Tables  and  Charts — Continued 

Table      Figure 

Number  Number  Page 

30  13     Mortality   of   children   with  reference  to   size   of  missionary 

societies   40 

31  14     Mortality  of  children  by  nationality  of  societies 41 

32  15    Mortality  of  children,  by  birthplace  of  parents 41,  42 

33  16     Mortality  of  children,  by  medical  training  of  parents 43 

34  17     Mortality  of  children  by  medical  training  of  parents  and  by 

sections  of  China 44 

35  18     Mortality  of  children  by  medical  training  of  parents  and  by 

groups   of  societies 45,  46 

36  Percentage  of  physicians  to  the  total  adult  missionary  force, 
by  societies  47 

37  Mortality   of   children   by   length   of   time   parents   have  been 
married    48 

38  19     Mortality  among  first  and  second  born  children  by  number  of 

years  parents  have  been  married 49 

39  20     Mortality  of  children  by  order  of  birth 50 

40  21     Mortality  of  children  by  number  of  children  in  family 51 

41  22     Mortality  of  children  by  birthplace 52 

42  23     Mortality  from  various  diseases  by  sections  of  China 54 

43  24     Mortality  of  children  from  various  causes,  by  societies. ..  .56,  57 

44  25     Mortality  of  children  from  various  diseases  by  nationality  of 

missionary  societies  58 

45  Mortality   of  children   from   various   causes   by   birthplace  of 
parents   59 

46  26     Mortality  of  children  from  various  causes  by  medical  training 

of  parents 59,  60 

47  27     Mortality  of  children  from  various  causes  by  number  of  years 

parents  have  been  married 60,  61 

48  28     Mortality  of  children  from  various  causes  by  order  of  birth. 61,  62 

49  29     Mortality  of  children  from  various  causes  by  number  of  chil- 

dren in  family 63 

50  30     Causes  of  deaths  of  children,  with  age  at  time  of  death 64,  65 

51  31-32-33  Percentage  of  deaths  occurring  at  specified  ages,  due  to  various 

causes,  compared  with  United  States  and  England 66-69 

52  Causes  of  deaths  occurring  outside  of  China 69 

53  34     Absolute  number  of  cases  of  principal  infections  and  number 

per  1,000  years  of  residence,  by  provinces 71,  72 

54  Number  of  principal  infections  by  sections  of  China,  and  occur- 
ring outside  of  China 73 

55  35-36     Number  of  principal  infections  per  1,000  years  of  residence  in 

China  and  occurring  outside  of  China 74,  75 

56  37     Percentage  of  mortality  for  various  diseases,  by  sections 76 

57  Number  of  infections  of  children,  by  provinces 77 

58  Number  of  infections  of  children,  by  societies 77 

59  Age  of  children  at  time  of  sickness 78 

60  Percentage  of  sicknesses  resulting  in  death  at  various  ages. ...  79 

61  41     Past  general  health  of  children,  by  provinces 80,  98 

62  Past  general  health  of  children,  by  societies 81 

63  Number   and   percentage   of   stillbirths   and    miscarriages,   by 
provinces    82 

64  Number  of  miscarriages,  by  provinces 83 

65  Summary  of  miscarriages,  by  sections 83 

66  Number  and  percentage  of  stillbirths,  by  societies 84 

6 


Tables  ajstd  Charts — Continued 

Table      Figure 

Aumber  Number  Page 

67  Causes  of  miscarriages  which  occurred  in  China 85 

68  Summary  of  principal  causes  of  miscarriage  occurring  in  and 
outside  of  China 86 

69  Average   number   of   married  years   and   proportion   spent   in 
China,  by  provinces 88 

70  Average   number  of  years   adults    (now  married)    have   been 
residents  in  China,  by  provinces 89 

71  Number  of  years  adults    (now  married)   have  been  residents 

In  China,  by  provinces 89 

72  Number  and  years  of  married  life  and  percentage  of  married 
life  spent  in  China,  by  societies 90 

73  Incidence  of  principal  infections  among  adults,  by  provinces. . .   92 

74  38-39     Number  of  sicknesses  per  100  married  missionaries,  in  order 

of  frequency,  by  sections 93,95 

75  Causes   of   invaliding  of  203   church  missionary   society   mis- 
sionaries     95 

76  Married  missionaries,  number  of  years  after  arriving  in  China 
when  sicknesses  were  contracted 96 

77  40     Percentage  of  husbands  and  wives  who  have  not  had  any  im- 

portant sickness  while  living  in  China 97 

78  41     Past  general  health  of  husband  and  wife,  by  provinces 98 

79  Past  general  health  of  husband  and  wife,  by  societies 99 

80  42     Sickness  from  typhoid  fever  among  married  missionaries  and 

United   States   soldiers 101 

43     Money  saving  which  would  result  from  reduction  of  typhoid 
fever  rate    102 

81  44     Mortality  from  smallpox  among  missionary  families    (adults 

and  children)   and  among  general  population  in  England  and 
the  United  States  103 

82  Cases  of  smallpox,  with  reference  to  previous  vaccinations. ..  .104 

83  Advice  concerning  health  by  missionaries 106 


Illusteations 

Pages  Facint 

Groups  of  Missionary  Children  in  Peking 86-87 


The  Health  of  Missionary  Families  in  China* 


A  Statistical  Study  by  the  heads  of  the  famihes  in 

collaboration  with  Wm.  G.  Lennox,  M.  D., 

Peking  Union  Medical  College 

Peking,  China 


Part  I— The  Health  of  the  Children 


INTRODUCTION 

Our  first  summer  in  China  was  one  full  of  anxiety  because 
of  the  protracted  illness,  with  dysentery,  of  one  of  our  chil- 
dren. The  question,  "How  can  we  serve  in  Chma,  and  at  the 
same  time  safeguard  the  life  and  health  of  the  children  en- 
trusted to  us?"  pressed  for  an  answer.  Realizing  that  the 
question  is  one  which  all  missionary  parents  in  China  must 
ask,  the  writer  decided  to  call  these  parents  into  consultation 
in  order  to  get  their  experience,  and  to  secure  the  basic  facts 
necessary  for  a  scientific  study  of  the  problem. 

Let  it  be  said  at  the  outset  that  this  study  is  the  work  of 
the  thirteen  hundred  heads  of  families  who  participated  in  it. 
The  writer  has  acted  merely  as  a  human  sorting  and  tabu- 
lating machine.  No  one  could  study  these  personal  accounts 
for  two  years  without  gaining  deep  respect  and  admiration 
for  the  devotion  and  courage  of  the  isolated  and  disease- 
beleaguered  missionaries,  who  count  not  their  lives  dear. 

"When  our  child  was  desperately  sick,"  writes  one 
mother,  "and  there  was  no  doctor  within  many  days'  journey, 
following  James  5:14,  we  anointed  him  with  oil  in  the  name 
of  the  Lord,  and  prayed  to  God  for  his  recovery." 

No  one,  let  it  be  said  also,  could  read  such  accounts  of  the 
extremities  in  which  parents  have  been  placed  without  gain- 
ing the  strong  desire  to  aid  in  stopping  the  preventable,  and 
therefore  useless,  portion  of  the  sacrifices  of  life,  and  of 
spirit. 

*  Presented  as  a  thesis  for  M.  A.  degree,  University  of  Denver. 

9 


10       The  Health   of  Missionary  Families  in   China 
THE  VALUE  OF  CHILD  LIFE  TO  MISSIONS 

Why  is  the  health  of  missionary  children  of  vital  impor- 
tance to  the  missionary  cause  ? 

1.  In  the  missionary  army,  unlike  other  armies,  wives 
and  children  are  an  integral  part  of  the  force.  How  many 
missionaries  have  been  forced  to  the  rear  because  members 
of  the  family  could  not  live  in  the  front  line  trenches  ?  How 
many  more  have  had  their  enthusiasm  for  work  or  the  work 
itself  undermined  by  the  eating  anxiety  over  the  sickness  or 
death  of  children? 

2.  The  children  of  missionaries,  because  of  their  inher- 
itance, and  their  inborn  knowledge  of  the  country,  form  the 
most  promising  of  any  body  of  prospective  missionary 
recruits. 

3.  The  existence  of  an  unnecessarily  high  death  rate 
among  children  would  be  a  cause  of  reproach  to  the  mission- 
ary body  and  would  deter  the  enlistment  of  conscientious 
married  volunteers. 

4.  It  is  a  well-recognized  axiom  that  in  any  community, 
infant  and  child  mortality  rates  furnish  an  index  to  the  health 
of  that  community.  Where  infant  death  rates  are  high,  the 
mortality  of  adults  is  also  above  normal. 

WHAT  THIS   STUDY   HOPES   TO   DO 

Modern  measures  for  the  promotion  of  health  rest  on  the 
foundation  of  vital  statistics.  The  first  step  in  any  intelligent 
effort  to  improve  the  health  of  a  community  is  the  collection 
and  digestion  of  the  facts  concerning  the  present  health  of 
that  community.  Just  so,  we  can  not  answer  the  question  of 
*'How  conserve  the  life  of  our  children?"  until  certain  other 
questions  are  answered,  e.g. : 

*'Do  children  in  China  suffer  more  than  their  fellows  in  the 
homeland  ? " 

*'What  diseases  are  most  to  be  feared — for  the  various  sec- 
tions of  China,  and  for  various  divisions  of  the  mission- 
ary body?" 

**At  what  ages  is  there  greatest  danger?" 

''What  harm,  if  any,  are  the  clearly  preventable  diseases 
doing?" 

''What  advice  can  those  who  have  been  long  years  in  China 
give  to  those  who  are  arriving?" 


The  Health  of  the  Children  11 

The  answers  to  these  and  similar  questions  will  clear  the 
ground  for  future  intelligent  action  looking  toward  the  better 
health  of  the  missionary  children.  Such  a  study  as  this  is 
only  preparatory.  If  it  does  not  result  in  action  by  mission- 
ary boards  and  by  missionaries,  the  time  given  to  it  by  the 
small  army  of  contributors  will  be  lost. 

It  should  be  said  that  the  collection  of  this  data  was  un- 
dertaken by  the  writer  on  his  own  responsibility.  The  results 
of  the  study  were  presented  to  the  conference  of  the  China 
Medical  Missionary  Association  and  received  the  approval  of 
its  members.  It  should  be  possible  to  make  such  a  study  as 
this  from  mission  board  records,  but  most  boards  have  not  as 
yet  seen  the  economy  of  money  and  life  which  would  result 
through  a  modem  system  of  vital  bookkeeping,  and  health 
information  which  they  possess  is  buried  in  the  files.  If  the 
information  were  collected,  it  would  have  little  to  say  con- 
cerning the  children. 

Though  it  is  evident  that  such  a  study  should  be  in  the 
hands  of  mission  boards,  there  is  a  certain  advantage  of  a 
personal,  unofficial  collection  of  data.  Many  missionaries 
wrote  more  frankly  than  they  would  to  a  non-medical  com- 
mittee. The  material  is  for  all  of  China  and  is  more  uniform 
than  if  gathered  by  separate  societies.  In  the  presentation  of 
material  the  writer  takes  the  view  that  the  Christian  forces 
in  China  should  present  a  united  front  and  a  united  program; 
and  that  the  important  facts  concerning  health  conditions 
should  be  known  by  all,  so  that  all  may  join  to  build  up  the 
weak  places. 


METHOD   OF   COLLECTING   DATA 

In  the  fall  of  1918  a  letter  with  question  blank  and  return 
envelope  was  sent  to  all  the  married  missionaries  listed  in  the 
missionary  directory.  Several  circumstances  have  delayed 
completion  and  have  prevented  one  hundred  per  cent,  accu- 
racy of  tabulation:  (1)  Replies  continued  to  come  in  for  more 
than  a  year  after  the  questions  were  sent  out.  This  meant 
doing  over  a  number  of  completed  tables.  Some  of  the  less 
important  ones  were  not  revised.  (2)  Many  blanks  were 
incompletely  filled  in,  figures  were  inconsistent,  or  handwrit- 
ing was  open  to  various  interpretations,  making,  accurate  tab- 
ulation difficult.  (3)  The  work  was  done  without  the  aid  of 
special  mechanical  tabulating  appliances  or  of  trained  clerical 
assistance.    Most  of  the  larger  tabulations  have  been  repeated 


12       The  Health   of  Missionary  Families  in   China 

several  times,  and  results  checked,  so  that  it  is  thought  that 
the  amount  of  error  from  faulty  arithmetic  is  small. 

Securing  information  concerning  family  health  through 
a  questionnaire  has  certain  limitations.  Such  a  method  would 
not  be  of  value  for  any  but  an  intelligent  group  of  persons. 
Because  the  missionary  body  is  an  intelligent  one,  practiced 
in  answering  questionnaires,  and  realizing  the  importance  of 
the  problem  of  keeping  well,  this  method  of  investigation  is 
possible.  Of  course,  certain  data  is  more  reliable  than  other. 
We  can  be  sure  that  parents  know  the  number  of  their  chil- 
dren living  and  dead,  and  years  of  marriage.  Other  items, 
such  as  the  various  sicknesses,  dates,  etc.,  will  not  be  so  reli- 
able, and  for  the  accuracy  of  these  returns,  allowance  must 
be  made. 

To  offset  the  error  which  is  associated  with  small  bodies 
of  figures,  the  data  obtained  has  been  viewed  from  many 
angles. 

The  writer  hopes  to  present  the  material  in  a  form  intel- 
ligible to  the  missionary  body,  many  of  whom  are  not  accus- 
tomed to  medical  terms  and  mortality  tables.  To  this  end, 
the  tables  of  most  practical  interest  are  illustrated  by  means 
of  charts.  In  many  tables,  for  the  sake  of  clearness  and  brev- 
ity, only  the  figures  giving  the  results  of  the  computations 
are  put  down.  Results  are  expressed  usually  to  the  nearest 
whole  numbers  only,  and  wherever  possible,  comparative  re- 
sults are  expressed  in  percentages. 


GENERAL  FACTS  CONCERNING  DATA 

2,220  letters  were  sent  out.  Answers  concerning  1,300 
marriages  were  received.  The  facts  hereafter  tabulated  relate 
to  3,254  children  of  missionaries,  including  general  facts  con- 
cerning 36  children  of  10  families,  furnished  by  Dr.  Elliott 
Illsgood  of  the  Foreign  Christian  Society.  These  36  are  in- 
cluded in  certain  of  the  tables,  only.  All  children  have  lived  a 
total  of  approximately  28,000  years,  nearly  18,000  of  which 
have  been  spent  in  China. 

Are  the  statistics  obtained  representative  of  the  whole  of 
China? 

Table  1  represents  the  percentage  of  returns  from  the 
various  provinces.  It  will  be  seen  that  there  is  considerable 
variation.  Results  for  provinces  near  the  head  of  the  list  will 
be  more  reliable  than  for  those  near  the  bottom,  as  they  rep- 
resent a  larger  portion  of  the  families  in  the  province. 


The  Health  of  the   Children 


13 


Table  1 


PERCENTAGE  ANSWERING  QUESTIONNAIRE  BY  PROVINCES 


PROVINCE 

PER  CENT 
ANSWERING 

PROVINCE 

PER  CENT 

ANSWERING 

Kansu 

93 
76 
75 
73 
70 
64 
68 
61 
58 

Kiangsu  _ 

58 
58 

ChihU  .                   .       

54 

Shansi              .. .. 

Hunan 

Kiangsi 

Hupeh 

52 

49 

49 

Fukien -. 

K  wangtung 

Yunnan 

48 
47 

Manchuria _ 

All  China 

42 

60 

Table  2 


PERCENTAGE  ANSWERING  QUESTIONNAIRE  BY  SOCIETIES 


SOCIETY 

Numlier  to  wliom 

Questionnaire 

was  sent 

Number 
Replying 

Per  cent 
Replying 

59 
64 
70 

223 
49 
92 

187 
71 

332 
69 
66 
53 

125 
59 
81 
91 

158 

270 

41 
51 
55 

159 
34 
63 

125 
48 

220 
42 
41 
31 
72 
30 
40 
42 
66 

108 

80 

80 

78 

71 

70 

Y.  M.  C.  A. 

68 

67 

67 

66 

62 

62 

60 

50 

50 

Church  Missionary  Society 

60 

European  C.  I.  M.  .,      

45 

42 

40 

Table  2  shows  the  variation  in  the  representation  by  soci- 
eties. The  replies  range  from  40%  to  80% — equidistant  from 
the  average  of  60%.  In  general  the  English  and  European 
societies  have  a  lower  representation  than  the  American.  In 
appraising  results,  these  factors  of  representation  need  to  be 
borne  in  mind. 

Very  few  replies  were  received  from  those  who  were  not 
in  China.  Presumably  the  questionnaire  did  not  reach  them. 
If  we  assume  that  tliis  number  is  15%  to  20%  of  the  total, 
we  find  that  75%  to  80%  of  the  married  missionaries  at  the 
time  in  China  answered  the  questionnaire,  a  high  figure,  as 
questionnaires  go. 

If  statistics  were  available  for  all  the  families,  in  place  of  the  60% 
here  represented,  they  would  probably  show  higher  sickness  and  death  rates 
than  are  here  presented.  This  is  because  of  the  fact  that  the  families  which 
have  been  hardest  hit  by  disease  are  not  now  on  mission  rolls,  and  conse- 
quently were  not  reached  by  this  questionnaire.  Again,  of  those  who  are  on 
the  mission  roll,  those  who  are  most  interested  in  the  health  of  their  chil- 
dren have  been,  in  all  probability,  most  successful  in  guarding  against  disease 
and  are  likely  to  be  the  ones  to  answer  a  questionnaire  of  this  sort.  (See 
Table  32.) 


14       The  Health   of  Missionary  Families  in   China 


THE   NUMBER    OF   CHILDREN 

CHILDREN  PER  MARRIAGE 

It  is  pertinent  to  inquire  whether  missionaries  have  borne 
their  full  share  of  children. 


Table  3 


NUMBER  OF  CHILDREN  BORN,  NOW  LIVING  AND  NOW  DEAD,  PER 
FAMILY  OF  MISSIONARIES,  BY  YEARS  OF  MARRIAGE 


No.  of 
families 

NUMBER  OF  CHILDREN 

No.  of  years 
parents  married 

Bom 

Now  living 

Now  dead 

Total 

No.  per 
family 

Total 

No.  per 
family 

Total 

No.  per 
family 

0-9 

10-19 

20-29 

30  and  over 

Years  not  stated 

G12 
389 
1G2 

57 
80 

984 
1,231 
664 
256 
119 

1.61 
3.16 
4.09 
4.49 
1.51 

881 
1,066 
540 
192 
115 

1.36 

2.74 

3.2 

3.39 

1.4 

92 

159 

130 

62 

10 

0.15 
0.42 
0.86 
1.08 
0.12 

Total 

1,300* 

3,254 

2.50 

2,794 

2.15 

453 

0.35 

*If  the  20  second  marriages  were  deducted,  the  children  per  family  would  number  2.54  in  place  of  2.50 

Table  3  gives  the  number  of  children  bom  to  each  family, 
arranged  by  the  years  of  the  parents'  marriage.  (Second 
marriages  throughout  are  counted  as  separate  families.) 

Investigations  of  the  Immigration  Commission^  for  rep- 
resentative sections  of  the  United  States  show  that  native 
white  women  whose  parents  were  native,  who  are  under  45 
years  and  have  been  married  from  10  to  19  years,  have  an 
average  of  2.7  children.  Missionaries  who  have  been  married 
the  same  length  of  time  have  an  average  of  3.16  children. 

A  more  accurate  comparison  is  with  a  group  of  American 
college  teachers.  Information  concerning  this  group  was 
kindly  furnished  by  the  Carnegie  Foundation  for  the  Ad- 
vancement of  Teaching,  and  is  summarized  in  Table  4. 


Table  4       SIZE  OF  FAMILIES  OF  FACULTY  MEMBERS  OF  AMERICAN  UNIVERSITIES 


RANK  OF  TEACHERS 

Number  of 
families 

Total  number 
of  children 

Average 
number  of 

children 
per  family 

Families  with  children 

Number 

Average  No. 
of  children 

Instructors . 

635 
1,049 
1,338 

906 
2,169 
3,502 

1.42 
2.06 
2.61 

401 

839 

1,183 

2.25 

Professors — Intermediate  Rank .. 

2.58 

Full  Professors 

2.96 

Total- 

3,022 

6,585 

2.18 

2,414 

2.68 

The  Health  of  the   Children 


15 


Another  fairly  just  comparison  is  with  American  college 
graduates.  Many  missionary  wives  are  not  college  women, 
but  it  has  been  shown  that  college  women  have  about  the  same 
number  of  children  as  their  female  relatives  who  have  not 
gone  to  college.^ 

Table  5  NUMBER  OF  CHILDREN  PER  FAMILY  FOR  VARIOUS  GROUPS  IN  COM- 

PARISON WITH  MISSIONARY  FAMILIES 


GROUPS 

Years  of 
graduation 

Number 
married 

Total 
number 
children 

Average 
number 
children 

Rmit.h  Cnllp^pl  fradnatps 

1871-1901 

1867-1901 
1890-1901 
1842-1909 

1,016 
961 

178 
974 

1,285 

1,579 

307 

1,973 

1.26 

Vassar  College  Kraduates          ._  .  

1.64 

1.71 

2.02 

Total  women  graduates 

1842-1909 

3,129 

5,144 

1.64 

1867-1886 

2.02 

Faculty  members  (Table  4) .  - 

3,022 
1,300 

6,585 
3,254 

2.18 

2.50 

A  glance  at  Table  5  shows  that  missionary  families  have 
a  distinctly  higher  birth  rate  than  these  other  educated  classes. 
This  in  spite  of  the  fact  that  nearly  one-half  of  the  marriages 
of  missionaries  were  concluded  less  than  ten  years  ago.  For 
the  219  marriages  which  took  place  more  than  20  years  ago, 
the  births  average  is  4.2. 

Among  85  Bryn  Mawr^  graduates  who  had  been  married 
ten  years  or  more,  births  averaged  2.2.  Among  608  mission- 
aries of  this  class,  the  number  is  3.5. 

If  childless  marriages  are  deducted,  the  average  children 
per  marriage  is  as  follows:  women  college  graduates,  2.13; 
college  teachers,  2.68 ;  missionaries,  2.80. 


Table  6 


NUMBER  OF  MARRIED  YEARS  PER  LIVING  BIRTH 
BY  GROUPS  OF  SOCIETIES 


ALL  FAMILIES 

FAMILIES  WITH  CHILDREN 

Groups  of  Societies 
(Those  with  lowest  mortality 
first) 

Average  No. 

years 

married 

Average  No. 
children 

Average  No. 
married 

years 
per  child 

Average  No. 

years 

married 

Average  No. 
children 

Average  No. 

married 

years 

per  child 

First 

10.2 
10.9 
13.5 

2.14 
2.56 

2.88 

4.7 
4.1 
4.5 

10.7 
11.3 
13,5 

2.50 
2,89 
3.32 

4.2 

Second 

3.9 

Third -... 

4.1 

Total - 

11.4 

2.50 

4.6 

12.1 

2.80 

4.1 

The  matter  of  birth  rates  may  be  presented  in  another 
way.     Table  6  shows  the  average  number  of  married  years 


16       The  Health   of  Missionary  Families  in   China 

per  child.  The  average  for  all  families  is  4.6  years.  In  con- 
trast, among  974  married  graduates  of  Mt.  Holyoke  College 
and  Seminary,*  the  child  hearing  married  years  per  child  num- 
ber 6.5.  That  is,  births  are  two  years  further  apart  than  with 
missionaries,  in  spite  of  the  fact  that  only  child-bearing  mar- 
ried years  are  counted. 


Table  7 


NUMBER  OF  CHILDREN  PER  FAMILY  BY  SOCIETIES 


All  Families 

Families  Without  Children 

Average  No. 

children 

of  families 

with 

children 

SOCIETY* 

Total 
number 

Total  No. 
of  children 

Average  No. 
of  children 

Number 

Per  cent 

Am.  Bapt..  North 

Am.  Ch.  Mission  

Am  Meth.,  North -.. 

45 
42 
73 
34 
63 
233 

99 

78 

197 

82 

120 

474 

2.20 
1.85 
2.70 
2.41 
1.90 
2.03 

5 
11 

0 
2 

7 
42 

11.01 
26.1 
8.2 
5.8 
11.1 
18.0 

2.47 
2.52 
2  94 
2.56 

Y.M.C.A 

Other  Am.  Societies 

2.14 
2.47 

Total  1st  group 

490 

1,050 

2.14 

73 

14.9 

2  50 

Canadian  Meth. 

48 
41 
126 
55 
53 
34 

134 

94 
314 
137 
138 

98 

2.79 
2.29 
2.41 
2.49 
2.60 
2.88 

3 

8 
14 
9 
6 
0 

6.2 
19.5 
11.1 
16.4 
11.3 

2  97 

Ch.  Miss.  Soc. 

2  87 

Am.  Pres.,  North  .       _   _ 

2  SO 

Am.  Luth.  Societies 

Am.  Board- 

2.99 
2 .  93 

2  88 

Total  2nd  group 

357 

915 

2.56 

40 

11  2 

2.89 

Other  Eng.  Soc . 

108 
156 
29 
67 
43 
41 

291 
449 
106 
171 
119 
139 

2.69 
2.87 
3.65 
2.59 
2.76 
3.39 

12 
25 
3 
10 

7 
2 

11.1 
16.0 
10.3 
15.1 
IG.2 
4.8 

3.38 

China  Inland  Mission 

Am.  Pre.'!.,  South. 

Other  European  Soc 

Am.  Bapt.,  South 

European  C.  I.  M 

3.42 
4.07 
3.05 
3.30 
3.56 

Total  3rd  group 

444 

1,275 

2.88 

59 

13.3 

3  32 

Society  not  stated  

9 

14 

1.55 

All  societies  .. 

1,300 

3,254 

2.50 

172 

13.1 

2  80 

*For  basis  of  division  into  Societies,  see  explanation  following  Table  26. 


Tables         NUMBER  OF  CHILDREN  PER  FAMILY,  AND  PERCENTAGE  OF  FAMILIES 
WITHOUT  CHILDREN,  BY  GROUPS  OF  SOCIETIES  OF  VARIOUS  NATIONS. 


All  Families 

Families 
without 

Average 

SOCIETIES 

Number 

Per  cent 
of  total 

Children 

children 

per  family 

having 
children 

Total 
number 

Average  No. 
per  family 

No. 

Per  cent 

762 
265 
107 
156 

59 

20 

8 

12 

1,782 
699 
310 
449 

2.33 
2.63 
2.89 
2.88 

110 
25 
12 
25 

14.4 
9 
11 
16 

2  73 

English  and  Canadian 

2.91 
3  ''6 

China  Inland _ 

3.42 

Throughout  this  study,  "Europe"  refers  to  continental  Europe. 


The  Health   of  the   Children  17 

Because  the  mission  body  is  composed  of  many  nation- 
alities, the  comparison  with  American  statistics  is  not  quite 
fair.  In  Table  7,  division  is  made  into  various  societies  and 
groups  of  societies,  and  these  are,  in  turn,  combined  in  Table 
8,  according  to  the  nationality  of  the  societies. 

It  will  be  seen  (column  3  of  Table  8)  that  English  and 
European  societies  have  more  children  than  American.  The 
average  of  2.33  for  American  societies  is  not,  however,  much 
below  the  average  for  the  whole — (2.50).  This  is  because  the 
families  of  American  societies  comprise  nearly  60%  of  the 
total. 

The  statement  has  been  made  that  the  upper  class  of  Eng- 
lish society  has  2.2  children  per  family.  English  and  Cana- 
dian missionary  societies  have  2.63  children  per  family. 

CHILDLESS   MARRIAGES 

A  corollary  to  this  question  is  the  proportion  of  the  mar- 
riages which  remain  childless.  In  the  class  of  American 
women  of  native  parentage  and  married  from  10  to  19  years,^ 
the  percentage  is  13.1.  Among  missionaries  married  the  same 
length  of  time  it  is  6.2,  less  than  half. 

All  missionaries  show  13.1  per  cent  of  the  marriages  so 
far  childless.  Among  teachers  in  American  colleges  the  per- 
centage is  20.  Among  3,594  married  women  graduates  of 
eight  American  colleges,^  who  had  graduated  ten  or  more 
years  previously  (classes  1870-1901)  the  percentage  without 
children  is  31.4. 

In  sharp  contrast,  missionaries  who  have  been  married 
ten  years  or  more  show  only  5.9  per  cent  childless  marriages. 

These  figures  are  of  great  interest,  as  they  show  (1)  that 
missionaries  have  not  hesitated  to  assume  the  responsibilities 
of  parenthood,  and  (2)  the  small  percentage  of  infertility  in  a 
group  of  persons  in  which  both  parents  are  free  from  the 
sterilizing  venereal  diseases.  (''Gonorrhea  is  the  cause  of 
70-75  per  cent  of  sterility  in  married  life,  not  of  choice."^) 

It  is  of  interest  to  inquire  not  only  the  average  number 
of  children  per  family,  but  also  the  number  of  children  in 
each  family. 


18       The  Health   of  Missionary  Families  in   China 

SIZE   OF    FAMILIES 

Table  9  PER  CENT  OF  FAMILIES  WITH  SPECIFIED  NUMBER  OF  CHILDREN  BORN, 

BY  YEARS  OF  PARENTS'  MARRIAGE 


Number  of 
j'ears 

Families 

Per  cent  of  families  having  specified  number  of  children 
born 

parents 
married 

Total 
number 

Per  cent 
of  total 

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

0-9 

612 
389 
162 
57 
80 

46.6 
28.9 
12.9 
4.4 
6.2 

17 
6.2 
2.5 
3.5 

46.2 

32.7 
12.4 
5.6 
1.7 
7.5 

29 

18.5 

10.4 

17.6 

22.5 

15.2 
22.4 
19.7 
14.1 
S.75 

5.1 
17.1 
27.7 
17.6 

6.3 

.6 
15 

14.1 
17.6 
6.3 

10-19 

20-29 

30  and  over 

Years  not  stated 

5.3 
8.0 
12.2 
1.3 

1.8 
4.3 
8.5 
1.3 

.5 
3.1 
1.7 

.3 
1.7 
5.3 

~".l 

'i'7 

% 
.6 

Total 

1,300 

99 

13.1 

20 

22.2 

17.4 

12.2 

7.6 

3.2 

1.5 

.74 

.52 

.07 

.07 

.15 

Table  9  gives  the  percentage  of  families  having  various 
numbers  of  children.  101  families  have  five  children,  43  have 
six,  20  have  seven,  9  have  eight,  7  have  nine,  one  has  ten,  one 
eleven,  and  two  have  twelve. 

For  those  married  ten  years  or  longer,  the  largest  num- 
ber (20.9%)  have  three  children,  closely  followed  by  those 
with  four  children  (20%).  Table  10  gives  the  contrasting  fig- 
ures for  American  college  teachers  and  married  graduates  of 
Vassar  and  Biyn  Mawr  colleges.  In  this  table  the  families 
having  more  than  four  children  for  the  various  groups  are: 
Vassar  and  Bryn  Mawr  graduates,  3.5%  ;  college  teachers, 
8.5% ;  missionaries,  13.6%. 


Table  10         SIZE  OF  FAMILIES  OF  AMERICAN  COLLEGE  TEACHERS,  OF  WOMEN 
COLLEGE  GRADUATES  AND  OF  MISSIONARIES 


GROUPS 

Number 
reporting 

Per  cent  of  families  having  specified  number  of  chil- 
dren born 

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

1! 

Full  professors 

1,338 

1,049 

635 

12 
21 
37 

17 
16 
15 

19 
24 
27 

24 
22 
13 

17 
12 

6 

9 
4 
9 

3 

2 
6 

.3 
.1 

.4 
.1 

.2 

.1 

Total  college  teachers 

3,022 

20 

16 

22 

21 

13 

6 

2 

.2 

.2 

.1 

.03 

1,703 
1,300 

38 
13 

24 
20 

19 

22 

11 
17 

4 
12 

2 

8 

.8 
3. 

.3 
1.5 

.1 
.7 

Missionaries _ 

.5 

.07 

.07 

.15 

Among  the  3,594  college  women^  who  graduated  ten  or 
more  years  ago  (classes  1881-1901)  the  percentage  with  two 
or  more  children  is  46.3;  among  missionaries  married  ten 
years  or  more,  this  percentage  is  80.  Here  again  allowance 
needs  to  be  made  for  the  European  societies,  among  whom  the 
largest  families  occur. 


The  Health   of  the   Children 


19 


Table  11         PERCENTAGE  OF  FAMILIES  WITH  SPECIFIED  NUMBER  OF  CHILDREN  NOW 
LIVING,  BY  YEARS  OF  PARENTS'  MARRIAGE 


Number  of  years 

Number 
of  families 

Per  cent  of  families  having  specified  number  of  children 

low  living 

parents  married 

0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

0-9 

612 

3S9 

162 

57 

80 

19.1 
8.2 
3.6 
3.5 

44 

35.6 
14.1 
16.1 

8.8 
11 

29.2 
22.5 
16.6 
21 

22 

12 

23.2 

22 

29.8 

11 

3.8 
18.8 
21.4 
14 

4.9 

.3 
9.7 
10.1 
5.3 
3.7 

10-19                 

15 
3.6 
10.5 
3.2 

1.8 
4.8 
5.3 

1.7 

20-29              .. 

.6 

Total 

1,300 

15 

23.8 

24.7 

17.4 

10.9 

4.8 

1.3 

1.3 

2 

.07 

Table  11  shows  the  percentage  of  families  having  various 
numbers  of  children  now  living. 


Table  12 


PERCENTAGE  OF  FAMILIES  WITH  SPECIFIED  NUMBER  OF  CHILDREN  NOW  DEAD. 
BY  YEARS  OF  PARENTS'  MARRIAGE 


Number  of  years 

Number 
of  families 

Per  cent  of  families  having 

specified  number  of  children  now 

dead 

parents  married 

0 

1 

2 

3 

4 

5 

6 

0-9 

612 
389 
162 

57 
80 

87.4 
67.8 
51.9 
36.8 
92.4 

10.3 
25.3 
25.9 
36.8 
3.7 

2.1 
5.3 
15.4 
15.6 
2.5 

,1 
.1 

4.9 

5 

1.3 

10-19 

.1 
12 
1.6 

20-29 

.6 

3.4 

Total 

1,300 

75.2 

17.5 

5.3 

1.3 

.3 

.2 

.1 

Table  13 


PERCENTAGE  OF  FAMILIES  WITH  SPECIFIED  NUMBER  OF  CHILDREN  DEAD, 
BY  SOCIETIES 


SOCIETY 

Number 
of  families 

Per 

cent  of  families  having  specified  number  of  chil- 
dren dead 

0 

1 

2 

3 

4 

5 

6 

45 

42 
63 

223 
34 
73 
48 

126 
41 
55 

108 
53 
66 

156 
34 
43 
29 
41 

87 
86 
86 
82 
80 
79 
77 
77 
76 
74 
73 
71 
71 
69 
67 
60 
60 
49 

11 
14 
12 
14 
15 
19 
16 
16 
22 
17 
21 
19 
18 
19 
20 
23 
27 
27 

2 

Y  M  C.  A 

1 
3 
4 
1 
4 
5 
2 
6 
5 
9 
4 
8 
9 

12 
3 

21 

1 
.5 

Am  Meth.,  North 

2 

1 

Am  Pres    North 

2 

2. 

3 

1.3 

3 

1.3 
1.3 

'.h' 

1.3 

3 

20       The  Health   of  Missionary  Families  in   China 

Table  12  shows  the  families  having  various  numbers  of 
children  now  dead,  by  years  of  parents '  marriage,  and  Table 
13  shows  the  same  facts  by  societies. 

Three-fourths  of  all  families  have  had  no  deaths  among 
children.  Of  those  who  have  had  children  die,  less  than  a 
third  have  had  more  than  one.  Three  families  have  lost  four 
children,  three  have  lost  five,  and  one  has  lost  six.  These 
figures  are  exclusive  of  still  births. 

In  Table  13  the  societies  are  arranged  in  order,  with  those 
showing  the  largest  percentage  of  families  without  death  at 
the  top. 


Table  14 


AGES   AND   YEARS   IN   CHINA 

CHILDREN— PERCENTAGE  OF  YEARS  IN  CHINA,  BY  PROVINCES 


PROVINCE 

Percentage    of    time 
in  China 

PROVINCE 

Percentage   of  time 
in  China 

55.8 
66.5 
69.7 
67.1 
74.5 
72.6 

Hupeh 

Hunan 

Kweichow 

60.6 

73.7 

Chihli. 

83.1 

Shansi..   ..  

59.4 

68.6 

North  China  .            .  . 

68.2 

59.9 

Kwangtung 

Yunnan 

56.5 

Kiangsu..  .     _. .. 

72.9 
74.9 
79.8 
66.1 
76.9 

72.3 

5S.2 

All  China.-  -  - 

66.9 

Table  14  shows  the  percentage  of  the  children 's  life  which 
has  been  spent  in  China,  by  provinces.  Children  in  South 
China  spend  10  per  cent  less  time  in  China  than  those  in  North 
and  Central  China. 


The  Health   of  the   Children 


21 


Table  15        NUMBER  OF  YEARS  OF  LIFE  OF  CHILDREN,  AND  YEARS  SPENT  IN 

CHINA,  BY  SOCIETIES 


YEARS  OF  AGE 

YEARS  IN  CHINA 

SOCIETY 

Number 
reported 

Tola! 

years 
of  age 

Average 
years 
of  age 

Number 
reported 

Total 

years 

in  China 

Average 

years 
in  China 

Percentage 
of  time 
in  China 

Am.  Bapt.,  North  - 

91 

73 

192 

SO 

120 

426 

827 
424 

2,147 
856 
538 

3,101 

9.09 
5.81 
12.17 
10.69 
4.48 
7.27 

90 

74 

182 

79 

120 

409 

487 
209 

1,394 
419 
308 

2,742 

5.41 
2.82 
7.66 
5.58 
2  56 
6.70 

59 
50 
65 

Am.  Church  Mission _. 

Am.  Meth.,  North  -.     .   - 

London  Mission 

Y.M.C.A.--. 

Other  Am.  Soc 

48 
57 

88 

y»2 

7,893 

8.03 

'j64 

5,559 

5.b2 

Canadian  Methodist 

Church  Mission  Soc 

Am.  Pres.,  North- 

m 

90 
308 
137 
132 

98 

69-2 

763 
2,588 

668 
1,195 

997 

5.16 
8.48- 
8.40 
4.98 
9.05 
10,18 

133 
89 
304 
137 
137 
90 

503 

416 

1,737 

491 

803 
502 

3.78 
4.67 
5.71 
3.73 

5.86 
5.57 

73 
55 
67 

Am.  Luth.  Soc. 

71 

Am.  Board  Mission 

Eng.  Baptist  , 

69 
50 

Total  2nd  group... _ 

899 

6,903 

7.69 

890 

4  452 

5. 

Other  Eng.  Soc. 

289 
449 
94 
169 
112 
139 

2,694 
4,728 
955 
1,641 
1,717 
1,015 

9.32 
10.53 
10.16 

9.71 
15.33 

7.30 

283 
440 
95 
160 
109 
135 

1,664 
3,391 
600 
940 
7!0 
623 

5.bV 
7.70 
6.31 
5.90 
6.51 
4.61 

China  Inland  Mission 

Am.  Pres.,  South       _ 

71 
02 

Other  EuropeanSoc 

Am.  Bapt.,  South 

57 
42 

European  C.  I.  M 

63 

Total  3rd  group. 

1,252 

12,399 

9.90 

1,222 

7,786 

6.37 

63 

Society  not  stated 

14 

96 

6.85 

14 

91 

6.50 

94 

Total 

3,149 

27,291 

8.65 

3,030 

17,888 

5.8 

67 

Years  not  stated. . 

105 

903 

8.65 

174 

1,009 

5.8 

(Average  taken) 

Total  all  Societies 

3,254 

28,194 

8.65 

3,254 

18,897 

5.8 

67 

Table  15  shows  the  age  of  children,  years  in  China  and 
percentage  of  time  in  China  by  societies,  the  societies  being 
arranged  in  order  of  mortality  of  children,  with  those  having 
the  smaller  percentage  of  deaths  at  the  top.  The  relation  of 
age  of  children  and  percentage  of  time  in  China  to  mortality 
is  shown  in  Figure  12. 

In  this  and  some  other  tables,  e.g..  Table  26,  the  number  not  answering 
the  point  in  question  is  entered  in  the  table.  In  most  of  the  tables,  in  order 
to  save  space,  this  is  not  done,  so  that  the  total  children,  total  deaths,  etc.,  at 
the  bottom  do  not  in  all  the  tables  coincide.  As  has  been  pointed  out,  there 
is  in  some  tables  a  small  percentage  of  error  due  to  the  fact  that  almost  all 
the  arithmetic  was  done  by  head  rather  than  by  machine. 


22       The  Health  of  Missionary  Families  in   China 


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The  Health  of  the  Children 


23 


Table  16  gives  the  number  of  children  now  living  at  vari- 
ous ages,  by  provinces.  The  total  for  each  year  is  represented 
in  Figure  7. 

MASCULINITY 

The  number  of  children  dealt  with  is  not  large  enough 
to  make  division  of  statistics  into  male  and  female  of  value. 
It  is  of  interest,  however,  to  note  the  relation  of  total  male 
and  female  births  and  deaths.  In  Table  17  the  births  and 
deaths  are  divided  into  groups  of  provinces.  Group  3  com- 
prises the  provinces  having  the  highest  child  mortality  and 
Group  1  those  with  the  lowest.  In  those  where  the  death  rate 
is  highest  the  number  of  boys  born  is  lowest.  Of  the  total 
births  there  are  1,032  boys  to  1,000  girls,  about  the  usual  pro- 
portion. For  every  1,000  girls  who  have  died,  1,267  boys  have 
died.  This  means  that  the  living  boys  and  girls  are  equal  in 
number — 1,310  of  the  former  to  1,312  of  the  latter. 


Table  17 


RELATION  OF  MALE  TO  FEMALE  BIRTHS.  BY  GROUPS  OF  PROVINCES 


Total  living  births 

Number 
male 
births 

to  1,000 
female 

Total  deaths 

Number 
male 

GROUP 

Male 

Female 

Sex  not 
stated 

Male 

Female 

Sex  not 
stated 

deaths 
to  1,000 
female 

3 
2 

1 

561 
572 
414 

573 
557 
369 

50 
61 
46 

979 
1.027 
1,122 

no 

87 
40 

95 
63 
29 

14 
6 
1 

1,158 
1,381 
1,379 

Total 

1,547 

1,499 

157 

1,032 

237 

187 

21 

1,267 

Twins  are  reported  nineteen  times  (.6%  of  the  total).  In  six  cases 
there  were  twin  sons,  in  seven  cases  twin  daughters,  in  five  cases  half  and 
half,  and  in  one  case  sex  was  not  stated. 


CONDITIONS  AFFECTING  CHILDREN 

There  is  a  variety  of  conditions  which  react  adversely 
on  foreign  children  in  China.     These  are,  briefly: 

(1)  Low  moral  atmosphere — of  non-Christian  Chinese 
servants,  etc.,  and,  in  port  cities,  of  non-Christian  foreigners. 

(2)  Conditions  which  may  affect  the  nervous  poise  of  the 
child:  isolation,  occasionally  fright  from  Chinese  mobs,  and 
almost  constantly,  unnatural  tension  over  food  and  drink. 

'*My  father  is  dead,"  said  one  child.  Quickly  her  play- 
mate asked,  "What  did  he  eat?" 


24       The  Health  of  Missionary  Families  in   China 

"My,"  said  another  little  girl,  on  reaching  a  Vancouver 
hotel  en  route  from  China,  "isn't  it  grand  to  take  a  bath  in 
drinking  water?" 

(3)  Lack  of  proper  educational  and  social  advantages. 

(4)  Diflficulty  in  maintaining  physical  health  because: 
{a)  of  climate,  sun,  lack  of  space  for  play;  {h)  because  of  diffi- 
culty in  obtaining  good  fresh  milk  and  other  elements  of  a 
balanced  diet  or  sufficient  vitamins  from  fruit  which  is  pared 
and  vegetables  which  are  cooked,  and  (c)  because  of  the  prev- 
alence of  infectious  diseases. 

All  these  phases  of  child  life  are  important.  This  study 
is  concerned  chiefly  with  the  question  of  physical  health. 


COMPARATIVE  MORTALITY 

MISSIONARIES    AND    CHINESE 
Table  18     MORTALITY  OF  CHILDREN  OF  MISSIONARIES  AND  OF  LOWER  CLASS  CHINESE 


Total 
Births 

Number  of  Deaths 

Number  of  Deaths 
Per  1,000  Births 

CHILDREN  OF 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

3,254 
8,468 

451 
2,751 

366 
2,203 

196 
1,321* 

139 
325 

121 

272 

60 

156* 

♦Number  infant  deaths  unreliable  because  of  Chinese  method  of  counting  ages. 


Figure  1.  Mortality  of 
Children  of  Mission- 
aries and  of  lower 
class  Chinese.  (Illus- 
trating Table  18.) 


How  does  the  death  rate  among  mis- 
sionary children  compare  with  that  of 
the  Chinese  among  whom  they  live?  In 
order  to  answer  this  question,  the  writer* 
had  inquiry  made  of  4,000  male  patients 
who  attend  the  dispensary  of  the  Union 
Medical  College  in  Peking.  Compara- 
tive mortality  is  shown  in  Table  18  and 
Figure  1. 

How  do  the  rates  for  children  of  mis- 
sionaries and  children  of  non-missionary 
foreigners  compare?  The  writer  knows 
of  no  data  for  children.  Statistics  for  a 
small  number  of  persons  in  Africa^ 
showed  the  following  number  of  deaths 
per  1,000  persons:  European  officials, 
8.10;  non-officials,  8.49;  missionaries, 
31.7. 


The  Health  of  the   Children 


25 


MISSIONARIES  IN  CHINA  AND  JAPAN 

Table  19      MORTALITY  OF  MISSIONARY  CHILDREN  IN  CHINA  AND  IN  JAPAN 


Number  of 
Living 
Births 

Number  of  Deaths 

Number  of  Deaths 
Per  1,000  Living  Births 

COUNTRY 

Total 

0-5 
Year3 

0-1 
Years 

Total 

0-5 
Years 

0-1 
Years 

China 

3,254 
377 

451 
36 

366 
28 

196 
20 

139 
95 

112 
74 

60 

Japan 

53 

How  does  the  death  rate  among  chil- 
dren in  China  compare  with  that  in 
other  mission  fields?  The  writer  has 
sent  a  questionnaire  to  all  missionary 
families  in  Japan.  The  answers  so  far 
received,  as  shown  in  Table  19  and 
Figure  2,  reveal  a  much  lower  rate  in 
Japan  than  in  China,  the  largest  dif- 
ference occurring  in  children  over  1 
and  under  5  years.  Mission  doctors 
in  Seoul  are  making  a  similar  study 
for  missionaries  in  Korea. 

How  does  the  rate  among  mission- 
ary children  in  China  compare  with 
rates  in  the  home  lands? 

It  is  hardly  fair  to  compare  the  mis- 
sionary group  with  the  general  popu- 
lation, for  the  following  reasons :  Missionaries  are  far  above 
the  average  in  education  and  intelligence;  they  have  passed 
physical  examinations ;  they  are  free  from  the  diseases  which 
lie  behind  such  a  large  proportion  of  the  deaths  of  children, 
viz.,  the  venereal  diseases  and  alcoholism. 

Another  difficulty  is  that  general  mortality  statistics  are 
based  on  the  number  of  persons  dead  to  the  number  living,  in 
any  geographical  or  age  group  for  a  certain  year,  whereas  in 
this  study  births  and  deaths  extend  over  many  years  and  the 
number  living  in  any  one  year  is  not  known. 

In  order  to  secure  figures  for  accurate  comparison,  the 
writer  is  at  present  sending  questionnaires  similar  to  those 
used  in  China  and  Japan,  to  ministers  and  educated  church 
members  in  America.  A  comparison  of  health  conditions  in 
these  three  groups  will  be  presented  in  a  later  paper. 


Figure  2.  Mortality  of 
missionary  children  in 
China  and  Japan.  (Illus- 
trating Table  19.) 


26       The  Health  of  Missionary  Families  in   China 

In  the  meantime,  there  is  some  value  in  comparing  results 
obtained  with  available  government  statistics.  The  mission- 
aries participating  in  this  study  have  been  married  an  average 
of  11.4  years.  Wherever  possible,  statistics  corresponding  to 
this  time  period,  rather  than  the  latest  returns,  are  used. 

INFANT   MORTALITY 

First :  in  regard  to  infant  mortality. 

This  term  means  in  government  statistics  the  number  of  infants  under 
one  year  old  who  have  died  in  a  certain  year  per  1,000  babies  born  alive  dur- 
ing that  same  year.  In  this  study  it  means  the  number  of  infants  who  have 
died  per  1,000  born.  Instead  of  one  year,  it  covers  a  number  of  years.  There 
are  two  sources  of  error.  First,  there  are  177  infants  not  yet  a  year  old. 
Probably  five  of  these  will  die  before  reaching  a  year.  This  would  raise  the 
infant  mortality  from  60.2  to  61.7,  a  small  difference.  The  second  possible 
source  of  error  is  larger.  The  parents  of  15  babies  made  the  report  "Died 
at  birth."  It  is  assumed  that  these  babies  were  dead  when  born,  and  they 
are  therefore  classed  among  the  still  births.  If,  however,  they  were  alive 
when  born,  they  should  be  classed  as  infant  deaths,  and  this  would  raise  the 
infant  mortality  rate  from  60.2  to  64.7.  This  indefiniteness  concerning  infants 
dying  at  birth  is  a  source  of  error  in  most  mortality  statistics. 


Table  20 

PERCENTAGE  OF  INFANT  DEATHS  OCCURRING  BY  MONTHS  FOR  UNITED  STATES' AND  VARIOUS 
CLASSES  OF  ENGLISH  SOCIETYs,  AND  FOR  MISSIONARY  CHILDREN 


Infant 
Mortality 

Infant  Deaths  Occurring  in  Specified  Months 

Under 
1  Mo. 

1-2 

3-5 

6-11 

171 
151 
90 
76 
69 
42 
60 

Percentage 
27 
24 
50 
39 
44 
50 
34 

Percentage 
IS 
21 
17 
19 
21 
14 
6 

Percentage 
21 
19 
15 
17 
20 
14 
21 

Percentage 
34 

35 

United  States  children  of  native  born  mothers 

IS 

24 

15 

Professional  and  business  group  in  England-  . 

22 
39 

Table  20,  Column  1  gives  infant  mortality  rates  for  vari- 
ous groups  of  English  and  American  society. 

In  this  comparison,  missionary  infants  show  up  very  well 
(60  against  42  for  the  children  of  English  professional  and 
business  men).  There  is  a  striking  difference,  however,  in  the 
distribution  of  deaths  during  the  first  year,  as  shown  in  Table 
21  and  Figure  3. 


The  Health  of  the   Children 


27 


Table  21         INFANT  MORTALITY  OCCURRING  BY  MONTHS  FOR  TWO  CLASSES  OF 

ENGLISH  SOCIETYio  AND  FOR  MISSIONARY  CHILDREN 

Number 
of  Births 

Number  of  Deaths  Per  1,000  Births 

0-1 
Year 

0-1 
Month 

2-3 

Months 

4-6 

Months 

7-12 
Months 

Factory  laborers  in  England 

Professional  and  business  groups  in  England 
Missionaries  in  China.. _ 

80,919 
8,658 
3,20t 

171 

42 
60 

46.3 

21 

20.9 

31.7 
6.2 
3.4 

36.4 
6.2 
12.8 

56.8 

8.1 
23.4 

Figure  3.  Infant  Mortality  by  Months 
for  two  classes  of  English  Society 
and  for  missionary  children.  (Illus- 
trating Table  21.) 


In  communities  where  in- 
fant death  rates  are  low,  a 
larger  proportion  of  the  in- 
fant deaths  occur  in  the 
first  months  of  life  than  in 
communities  where  rates 
are  higJi."  (This  because  of 
the  unpreventable  accidents 
and  defects  at  birth.) 
Among  missionary  chil- 
dren, however,  39%  of  the 
deaths  occur  in  the  last  half 
of  the  year,  giving  a  curve 
which  follows  that  of  Eng- 
lish factory  laborers.  The 
cause  of  this  upward  turn 
is  shown  in  Table  50.  31  of  the  67  deaths  during  these  six 
months  were  due  to  intestinal  infection,  viz.,  dysentery,  infec- 
tious diarrhoea,  cholera,  and  typhoid.  Were  it  not  for  these 
infections,  the  infant  rate  would  nearly  equal  that  of  the  fav- 
ored English  class,  which  it  actually  surpasses  for  the  first 
six  months.  Breast-fed  babies  have  no  right  to  these  infec- 
tions. Many  mothers  complained  that  they  were  able  to  nurse 
their  babies  but  a  few  months,  which  fact,  with  the  consequent 
artificially  prepared  food,  accounts  in  large  measure  for  the 
rising  death  curve  after  the  first  six  months.  It  has  been 
shown  that  the  mortality  among  bottle-fed  infants  in  New 
York  is  12  times  what  it  is  among  the  breast-fed.^-  The  ratio 
in  China,  where  clean,  fresh  milk  is  hard  to  get,  and  dysentery 
is  rife,  is  probably  not  less.  The  extent  and  cause  of  this 
inability  to  nurse  needs  special  investigation.  If  it  is  found 
that  too  much  mission  work  is  responsible,  the  price  paid  for 
that  work  is  a  high  one. 


28       The  Health   of  Missionary  Families  in   China 

MORTALITY   IN   EARLY   CHILDHOOD 

The  hope  aroused  by  this  comparatively  low  infant  mor- 
tality of  finding  a  low  death  rate  among  children  is  quickly 
dashed.  In  comparing  various  city  rates  with  the  English 
"Healthy  District  Life  Table,"  English  health  officers  have 
shown  that  children  are  most  affected  by  an  unhealthy  envi- 
ronment during  the  third  year  of  life/^  From  this  high  point 
the  curve  sinks  gradually  to  the  tenth  year,  when  unhealthy 
cities  show  little  more  mortality  than  the  ** Healthy  Districts." 
This  finding  is  verified  in  these  statistics. 


Table  22 

MORTALITY  FOR  THE  FIRST  TEN  YEARS  AMONG  MISSIONARY  CHILDREN 

AND  AMONG  CHILDREN  IN  AMERICA  AND  ENGLAND 

Number  of  Deaths  Per  1,000  Living 

Number  of 

) 

Missionary  Children 

1        Children  of 

General 

Year 

Alive  at  Begin- 

Deaths During 

Children  of 

Native  White 

Population 

of  Age 

ning  of  Year 

That  Year 

Missionaries 

Parents,  U.  S.  A. 
1900 

England  and  Wales 
1904-1908 

0-1 

3,212 

194 

60 

133 

117 

1 

2,841 

87 

31 

32 

35 

2 

2,587 

48 

18 

14 

14 

3 

2,332 

17 

7 

9 

9 

4 

2,147 

19 

9 

7 

7 

5 

1,967 

12 

6 

6 

6 

1,820 

15 

8 

5 

7 

1,673 

5 

3                                4 

8 

1,534 

10 

6               '.                 3 

9 

1,399 

4 

3               1                , 

---- 

Figure    4.     Mortality    for    the    first  ^^|"^^    ^-     Mortality    of    the    first 
fivP  vears  imone  rnism-nnarv  rhil  ^^®  ^^^^^  among  missionary  chil- 

JLr,  oi^r.h^U.  Tf  ^i?-^!  Lf  dren  and  children  in  England  and 

dren  and  children  of  white  native-  Wales     (Illustratin-  Table  2"?  ^ 

born     Americans.        (Illustrating  ^^^^^-    UHustratm^  iable  16.) 

Table  22.) 

Infant  deaths,  as  shown  in  Table  22  and  Figures  4  and  5, 
for  the  general  population  of  England^''  and  the  native  white 
population  of  the  United  States,^  are  more  than  double  the 
missionary  rate,  but  after  the  first  year  deaths  are  about  the 
same. 


The  Health  of  the  Children 


29 


Table  23        CHILD  AND  INFANT  MORTALITY  IN  CITY  AND  COUNTRY  DISTRICTS  OF 
ENGLAND  (1914;  COMPARED  WITH  THAT  OF  MISSIONARY  CHILDREN 

NUMBER  OF  DEATHS  PER  1,000  LIVING 

0-1  Year            j              1  Year 

2-3-4  Years 

130 
66 
60 

55.7 
11.7 
30.6 

13.5 

3.8 

11.2 

If,  as  in  Table  23,  we  compare  our 
rates  with  the  cities  of  North  England,^" 
we  find  the  same  condition,  a  relatively- 
high  rate  for  missionary  children  for 
the  ages  2,  3  and  4.  If  we  compare 
with  the  rural  districts  of  South  Eng- 
land, where  infant  death  rates  are  near- 
ly as  low  as  missionary,  we  find  that 
during  the  second  year  missionary  rates 
are  more  than  double,  and  during  the 
third,  fourth  and  fifth  years  are  three 
times  the  rates  of  the  country  districts 
of  England.  This  is  illustrated  in 
Figure  6.  Differences  in  the  methods  of 
arriving  at  results  make  comparison  of 
the  two  curves  of  more  value  than  com- 
parison of  any  two  points  on  the  two 
curves.  These  comparisons  show  clearly  an  excessive  mortal- 
ity for  the  second,  third  and  fourth  years  of  life.  These  years, 
rather  than  the  first  year,  are,  compared  with  the  homeland, 
the  dangerous  ones  for  missionary  children.  These  compari- 
sons are  made  with  English  and  American  statistics  rather 
than  with  European,  because  only  about  one-tenth  of  the  chil- 
dren are  from  European  societies.  Except  for  Germany, 
which  has  a  high  rate,  infant  mortality  rates  in  Northern 
European  countries  are  lower  than  those  in  England  and 
America. 

For  the  five-year  period  from  1906  to  1910,  the  following 
was  the  infant  mortality  rate  in  various  countries  ■}*  United 
States,  124;  England  and  Wales,  117;  Netherlands,  114;  Scot- 
land, 112 ;  Denmark,  108 ;  Sweden,  78. 


Figure  6.  Mortality  in 
first  five  years  among 
Missionary  Children 
and  children  in  rural 
districts    of    England. 

(Illustrating  Table  23.) 


30       The  Health  of  Missionary  Families  in   China 


Table  24 


PERCENTAGE  OF  CHILDREN  DYING  AND  PERCENTAGE  NOW  LIVING, 
AT  VARIOUS  AGES 


AGE 

Percentage  Dying 
At  Specified  Age 

Percentage  Now  Living 
At  Specified  Age 

0-1 _.. ..._ 

43.6 

19.6 

10.8 

3.8 

4.2 

2.7 

3.4 

1.1 

2.2 

.9 

4.2 

3.8 

6.6 

1 ..                _ 

6.6 

2 

7.7 

3 ... 

6.1 

4 

6.1 

5 .                            .                 

6.2 

6.... 

5. 

7 

5. 

8 

4.7 

9 

4.2 

10-19 _ 

26. 

14.4 

Total--     

100.3 

99.1 

D  EA  D  -   PERCEN  TAQE     OP    TOTAL    NUMBER.    DEAD 
LIVINQ-  PERCENTAGE    OF  TOTAL    NUMBER.    UIVINQ 


U3. 


IIM 


Q 


Sfl 


13        ^ 


^  1  M  « 


<?       lO-lcj  7.0  + 


Figure    7.     Percentage    of   children    dying    and    percentage    now 
living  at  various  ages.     (Illustrating  Table  24.) 


Table  24  and  Figure  7  show  the  number  of  children  dying 
at  various  ages  in  relation  to  the  number  now  living. 


FACTORS   IN   CHILD   MORTALITY 

In  any  analysis  of  the  causes  of  child  mortality,  there  are 
numerous  factors  to  be  considered.  Those  on  which  this  study 
throws  some  light  will  be  considered  first. 


The  Health  of  the  Children 


31 


GEOGRAPHICAL   LOCATION 

In  Table  25  is  presented  the  number  and  percentage  (or 
per  thousand)  of  children  dying  in  the  various  provinces  in 
which  parents  reside. 

In  the  cases  in  which  parents  have  lived  in  various  provinces,  their 
residence  is  considered  to  be  that  in  which  they  have  lived  longest.  This 
Involves  some  error,  as  some  children  have  contracted  disease  while  away 
from  home  at  school.  To  offset  this  error  and  to  provide  larger  figures  for 
generalization,  the  IS  provinces  are  grouped  into  three  sections — North, 
Central,  and  South  China.  The  basis  for  this  division  is  the  statement  of 
the  China  Year  Book,i5  defining  North  China  as  north  of  the  35th  parallel. 
South  China  as  south  of  the  28th  parallel,  with  Central  China  lying  between. 

Returns  from  some  of  the  provinces  are  too  small  to  make  tabulation 
of  value.  Thus  the  returns  from  Yunnan  and  Kwangsi  are  included  in  those 
from  Kwangtung;  those  from  Kueichow  with  Hunan;  and  those  from  Sin- 
kiang  and  Mongolia  with  Manchuria. 

Western  China  means  practically  Szechuan,  for  returns  from  other 
western  provinces  are  scant.  The  provinces  in  Table  25  are  arranged  from 
north  to  south. 

It  will  be  seen  that,  in  general,  the  highest  rates  of  mor- 
tality are  in  the  northern  provinces. 


Table  25 


MORTALITY  OF  CHILDREN  BY  PROVINCES  ARRANGED  BY  GEOGRAPfflCAL 

SECTIONS 


PROVINCE 

Total 
Number 
of  Living 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

Manchuria 

85 
289 
270 
154 
84 
76 

20 
55 
39 
29 
23 
12 

17 

39 

32 

28 

19 

7 

9 

22 
16 
24 
10 

3 

235 
190 
144 
195 

274 
158 

200 
135 
118 
182 
226 
92 

106 

76 

Chihii 

59 

Shansi-     

91 

119 

39 

North  China 

958 

178 

142 

74 

186 

148 

77 

Kiangsu.. 

448 
94 
17G 
229 
70 
196 
216 
311 

01 

7 

19 
41 

7 

27 
26 
41 

50 
7 
13 
33 
fi 
19 
22 
35 

27 
4 
9 

16 
3 
9 

11 

19 

137 
75 
106 
179 
100 
137 
120 
131 

112 
75 
73 

144 
82 
97 

102 

112 

60 

43 

Chekiang  . 

51 

Honan .. 

78 

42 

Hupeb..   . 

46 

Hunan,  Kueichow 

50 

Szechuan- . 

61 

Central  China 

1,740 

228 

185 

98 

130 

106 

56 

Fukien  .. 

182 
324 

12 
30 

9 

27 

7 
17 

68 
92 

49 
87 

38 

Kwantung,  Yunnan 

52 

South  China .. 

506 

42 

36 

24 

83 

71 

47 

Total— All  China 

3,204 

448 

363 

196 

139 

113 

61 

32       The  Health   of  Missionary  Families  in   China 


Figure  8.     Mortality  of  Missionary  Children  by  provinces.    (Illus- 
trating Table  25.) 


Table  25  is  illustrated  by  Figure  8,  and  also  by  the  frontis- 
piece. Note  that  provinces  with  the  lowest  rates  (the  first  five 
in  the  chart)  have  a  relatively  small  number  of  children  dying 
between  the  ages  of  1  and  5.  In  columns  representing  prov- 
inces with  high  rates  this  portion  is  greatly  elongated,  showing 
again  that  this  is  the  danger  age  for  children  in  China,  as 
compared  with  those  at  home.  This  finding  of  excessive  rates 
in  North  China,  rather  than  in  the  south,  was  such  a  surprise 
that  the  question  has  been  examined  from  a  number  of  angles, 
as  will  be  seen  later. 


The  Health  of  the  Children 


33 


Figure  9  shows  the  mortality  for  the  three  sections  of 
China.  To  make  sure  that  the  high  mortality  for  North  China 
was  not  due  to  a  longer  residence  by  the  children  in  that  sec- 
tion, the  number  of  deaths  per  1,000  years  of  residence  was 
calculated  and  compared  with  the  mortality  rates  based  on 
number  of  births.  Figure  10  shows  that,  viewed  from  either 
angle,  North  China  has  the  highest  rates.  If  Honan  were 
counted  with  North  China,  the  difference  between  deaths  for 
North  and  Central  China  would  be  increased  by  5  per  1,000 
births. 


Figure  9.  Mortality  of  chil- 
dren by  geographical  sec- 
tions. (Illustrating  Table 
25.) 


^^                              . -.PER    1000    rtARS 

\    .                        ■                     PIB.   1000    Bimii 

Z 

c 
s 

o 

0 

o 

K    110 

\\ 
\\ 
\\ 

a. 
r 
o 

eo 

h 

0 

J 

o 

K 

c 

i. 

z 
o 

?, 

r 
O 

CMIMA 

NORTH           1     CtNTHAl.        1        bOUTM 

Figure  10.  Deaths  of  children  per 
1,000  births  and  per  1,000  years  of 
residence  by  sections. 


MISSIONARY    SOCIETIES 

In  Table  26  and  Figure  11  the  tabulation  is  made  accord- 
ing to  missionary  societies.  Societies  reporting  75  or  more 
children  are  listed  separately.  Societies  are  arranged  in 
order  of  the  total  mortality,  the  lowest  at  the  top.  For  fur- 
ther analysis  societies  are  arranged  in  three  groups  of  six 
societies  each. 


34       The  Health  of  Missionary  Families  in   China 


Table  26 


MORTALITY  OF  CHILDREN,  BY  SOCIETIES 


Number 
Living 
Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

SOCIETY 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

Am.  Baptist,  North 

Am.  Church  Mia. 

99 
78 
197 
82 
120 
474 

7 
6 
16 
7 

12 
52 

7 
6 
15 
5 
11 
39 

5 
2 
7 
3 
8 
21 

71 
77 
81 
86 
100 
110 

71 

77 
76 
61 
92 
82 

50 
26 

Am.  Methodist,  North 

35 
37 

Y.  M.C.  A.. 

Other  Am.  Soc.  . 

66 
44 

Total — 1st  group 

1,050 

100 

83 

46 

95 

79 

44 

Canadian  Methodist 

Church  Mis.  Soc... 

134 
94 
314 
137 
138 
98 

15 
11 
38 
18 
20 
10 

14 
11 
29 
15 
15 
14 

8 
7 
14 
5 
6 
7 

112 
115 
121 
131 
145 
161 

104 
115 
92 
109 
108 
142 

60 

78 

Am.  Pres.,  North 

45 

Am.  Lutheran  Societies 

Am.  Board  Mis 

36 
43 

Eng.  Baptist. - 

71 

Total — 2nd  group 

915 

118 

98 

47 

128 

107 

61 

Other  Eng.  Soo 

291 
449 
105 
171 
119 
139 

40 
80 
20 
34 
27 
32 

33 
57 
15 
30 
21 
29 

18 
32 
9 
16 
13 
15 

172 
178 
190 
205 
228 
230 

115 
127 
140 
175 
176 
209 

63 

China  Inland  Mia 

66 

Am.  Prea.,  South 

84 

Other  European  Soc 

Am.  Baptist,  South 

European  C.  I.  M 

94 
109 
108 

Total— 3rd  group. 

1,275 

233 

185 

103 

182 

146 

81 

Society  not  stated. . 

14 

Total  all  Societle« 

3,254 

451 

366 

196 

139 

112 

60 

Figure    11.     Mortality    of    children    by    Societies. 

Table  26.) 


(Illustrating 


The  Health  of  the  Children 


35 


It  will  be  seen  that  results  vary  widely.  Death  rates  in 
the  first  group  are  only  a  little  more  than  one-half  what  they 
are  in  the  third.  Among  6  societies  (5  American  and  1  Eng- 
lish), of  1,420  children  bom  there  is  reported  an  infant  death 
rate  of  only  41. 

Are  high  death  rates  the  result  simply  of  certain  soci- 
eties having  older  children  or  more  children  than  others  or 
the  result  of  keeping  them  longer  in  China? 


A  / 
/A 


j^ 


A. 


y;r-^?-cv„„rt?.-- 


,     A     / 

7  \ 


■"A 


/ 
/ 

/ 

J 


A 

/\ 

/  I, 
I  A 


/J 


It 

V 


\     /  \ 


V 


\ 


// 

./.* 


\ 


V 


Figure  12.  Mortality  of  children  compared  with  average  age  of  chil- 
dren, average  number  of  children  per  family,  and  percentage  of  time 
spent  in  China,  by  societies.  (Illustrating  parts  of  Tables  7,  15,  and  26.) 


Figure  12  compares  these  factors  graphically.  None  of 
the  lines  parallel  the  line  expressing  the  total  mortality. 
Though  age  of  children  may  modify  figures  in  certain  cases, 
(e.g.,  we  might  say  that  the  American  Methodist  and  London 
missions  have  a  low  mortality  in  spite  of  having  older  chil- 
dren, and  the  Southern  Baptist  a  high  rate  because  of  this 


36       The  Health  of  Missionary  Families  in   China 

factor) ,  yet  age  of  children  is  not  a  predominant  factor.  The 
line  representing  the  size  of  the  families  does  rise  fairly  con- 
stantly with  the  mortality  line.  The  percentage  of  time  spent 
in  China  has  little  influence.  One  would  not  expect  it  to,  for 
children  are  rarely  sent  home  before  seven  years  of  age,  by 
which  time  88%  of  the  deaths  have  occurred.  It  is  the  reverse, 
naturally  enough,  of  the  curve  expressing,  the  average  age  of 
children,  for  the  older  the  child  the  more  time  has  he  spent 
at  school  outside  of  China. 


Societies  reporting  less  than  75  children  each  are  put  into  five  different 
groups,  following  national  rather  than  denominational  lines.  The  groups, 
with  the  societies  in  each,  are  as  follows.  The  numbers  refer  to  the  number 
of  families  reporting: 

1.  Other  American  Societies — Seventh  Day  Adventist,  31;  Christian 
Missionary  Alliance,  21;  Reformed  Church  in  America,  12;  Methodist  Epis- 
copal South,  11;  United  Evangelical  Church  Mission,  11;  Foreign  Church 
Mission  Society,  10;  Church  of  the  Brethren,  10;  Yale  Mission,  9;  China 
Mennonite  Mission,  9;  American  Reformed  Presbyterian,  8;  China  Medical 
Board,  6;  other  societies,  6;  Canton  Christian  College,  5;  Independent  Mis- 
sions, 5;  United  Brethren  in  Christ,  5;  American  Advent  Christian  Mission,  4; 
American  Bible  Society,  3;  American  Free  Methodist,  3;  University  of  Nan- 
king, 1;  Baptist  College,  Shanghai,  1;  South  Chihli  Mission,  4;  Assemblies 
of  God,  4;  Pentecostal  Church  of  Nazarene,  4;  Church  of  God,  3;  National 
Holiness  Mission,  3;  Apostolic  Faith  Mission,  2;  Seventh  Day  Baptist  Mis- 
sion, 1;  Methodist  Protestant  Mission,  1;  American  Friends  Mission,  1; 
Ebenezer  Mission,  1;  Grace  Mission,  1;  Hebron  Mission,  1;  North  Chihli 
Mission,  1;  Tsehchowfu  Mission,  1;  China  New  Testament  Mission,  1;  Glad 
Tidings  Mission,  1;  Evangel  Press,  1;  South  German,  2;  Peniel  Mission,  1. 

2.  American  Lutheran  Societies— Norwegian  Lutheran  Church  in  Amer- 
ica, 27;  Augustana  Synod  Mission,  10;  Swedish  American  Mission,  7;  Amer- 
ican Lutheran  Brethren,  5;  Lutheran  Board  of  Missions,  5;  Evangelical 
Lutheran  Synod  of  Missouri,  etc.,  3. 

3.  Other  English  Societies — Canadian  Presbyterian,  19;  Wesleyan  Meth- 
odist Mission,  17;  Christian  Missions  in  Many  Lands,  10;  British  and  Foreign 
Bible  Society,  10;  English  Presbyterian,  9;  United  Methodist  Mission,  8; 
United  Free  Church  of  Scotland,  8;  Church  of  England  Mission,  7;  Irish 
Presbyterian,  6;  Friends  Foreign  Mission,  2;  Salvation  Army,  3;  Canadian 
Church  Mission,  2;  Church  of  Scotland,  2;  Miscellaneous,  2;  National  Bible 
Society,  Scotland,  1;  Canadian  Holiness  Mission,  1, 

4.  European  Societies  Associated  with  China  Inland  Mission  — Scandi- 
navian China  All.  Mission,  11;  Swedish  Mission  in  China,  10;  Liebenzell  Mis- 
sion, 5;  German  China  All.  Mission,  5;  Swedish  Holiness  Mission,  5;  Swedish 
Alliance  Mission,  4;  Norwegian  Mission  in  China,  1;  Norwegian  Alliance 
Mission,  1. 

5.  Other  European  Societies — Basel  Mission  Society,  15;  Swedish  Mis- 
sion Society,  12;  Danish  Lutheran  Mission,  11;  Norwegian  Lutheran  Mission, 
7;  Norwegian  Mission  Society,  6;  Berlin  Mission  Society,  5;  Finland  Mission- 
ary Society,  5;  Swedish  Baptist  Mission,  4;  Free  Evangelical  Mission  of 
Norway,  1;  Kiel  China  Mission,  1;  Rhenish  Mission  Society,  1. 


The  Health  of  the  Children 


37 


Table  27 


MORTALITY  OF  CHILDREN 
IN  SOCIETIES  REPORTING  BETWEEN  20  AND  75  CHILDREN 


SOCIETIES 


Am.  Educational  Institutiona.. 

Christian  and  Miss.,  All 

Am.  Methodist,  South 

Seventh  Day  Adventists 

Refonned  Ch.  in -Am 

53 
51 
46 
43 
43 

Foreign  Christian  Miss.* 

Lutheran  United  Miss 

Swed.  Am.Miss.Cov 

Augustana  Synod. 

99 
72 
20 
20 

Scandinavian  All.  Miss. 

Swedish  MLss.  in  China 

Canadian  Pres 

43 

34 
67 

Wesleyan  Meth 

41 

Brit,  and  For.  Bible  Soc 

Ch.  of  Scotland... 

29 

27 

United  Meth 

24 

Ch.  Miss,  in  Many  Lands 

Danish  Luth.  Soc... 

21 
34 

32 

Basel  Miss 

29 

Total 
Birtha 


Number  Dead 


Total 


0-5 
Years 


0-1 
Y'ear 


Number  Dead  Per 
1,000  Living  Births 


Total 


109 
93 
23 

80 

in 

2,'iO 
50 
35 
176 
209 
146 
69 
185 

'233' 
324 
1S3 
103 


0-5 
Years 


57 
20 
109 
93 
23 
70 
83 
250 
50 
28 
176 
179 
122 
34 
74 

"23.S' 
324 
156 
i03 


0-1 
Year 


19 
20 

""76" 
23 
40 

'166" 
50 
14 
59 
104 
24 


143 

118 

63 

0 


♦Facts  concerning  36  children  supplied  by  Dr.  Illsgood  not  detailed  enough  to  allow  this  society  a  seperate 

place  in  tables. 

In  Table  27  is  shown  the  data  for  societies  reporting 
between  20  and  75  children.  The  numbers  dealt  with  are  too 
small  to  be  of  value,  but  the  table  is  inserted  for  the  benefit 
of  those  who  may  be  interested. 

SOCIETIES    IN    RELATION   TO    LOCATION 

An  important  question  now  arises.  Is  the  poor  showing 
made  by  some  of  the  societies  due  to  geographical  location^ 


Table  28 


PERCENTAGE  OF  CHILDREN  LIVING  IN  SECTIONS  OF  CHINA 
BY  SOCIETIES 


PERCENTAGE  OF  CHILDREN  LIVING  IN 

SOCIETY 

North  China 
(Including  Hon  an) 

Central  China 

South  China 

Am.  Bapt.,  North 

"32"" 
32 
32 
25 

63 
100 
39 
32 
51 
58 

36 

Am.  Church  MLs 

Am.  Meth.,  North.. 

28 

London  Mission 

36 

Y.  M.  C.  A 

17 

17 

Total— 1st  Group _ 

23 

56 

21 

Canadian  Methodist 

"39" 
60 
67 
100 

100 
53 
38 
40 

Church  Mis.  Soc...  .       . 

47 

Am.  Pres.,  North... 

22 

.Am.  Luth.  Societies  -       .... 

.Am.  Board  Mis 

33 

Ping.  Baptist. _. 

Total— 2nd  Group. 

43 

39 

17 

Other  Eng.  Soc.  _ 

37 
36 

If 

77 

45 

61 
100 
29 
35 
23 

18 

China  Inland  Mis...        ...  

3 

Other  Europ.  Soc 

27 

Am.  Bapt.,  South 

14 

European  C.  I.  M.           .          

Total— 3rd  Group 

40 

49 

0 

Total  All  Societies 

35 

48 

15 

38       The  Health   of  Missionary  Families  in   China 

In  Table  28  is  shown  the  percentage  of  children  reported 
from  North,  Central,  and  South  China  by  each  of  the  societies. 
In  this  and  the  following  table  Honan  is  included  in  North 
China.  This  is  done  to  make  the  numbers  more  nearly  even, 
and  also  because  Honan 's  mortality  rate  approaches  the  aver- 
age for  North  China  more  nearly  than  that  for  Central  China. 

Table  28  shows  that  geographical  location  does  have  some 
effect  on  society  mortality.  In  the  first  group  (with  lowest 
mortality),  21%  of  the  children  are  in  favored  South  China; 
in  the  second  group,  17%,  and  in  the  third  group,  only  9%. 
This  factor,  of  course,  is  only  one  of  many,  but  it  may  help  to 
explain  the  position  of  some  of  the  societies  in  the  table.  For 
example,  the  English  Baptist  group  might  be  higher  up  the 
list  were  not  all  the  children  in  North  China.  American  Bap- 
tist North  and  South  might  be  nearer  together  did  they  not 
belie  their  names.  The  Southern  Baptists  have  nearly  a  half 
of  their  children  in  North  China,  while  the  Northern  Baptist 
have  none  of  their  workers  in  the  north. 

Another  question  arises."  Possibly  the  reverse  of  the  fore- 
going assumption  is  true.  Possibly  the  relatively  high  mor- 
tality rates  from  North  China  are  due  to  the  societies  working 
there,  and  not  to  the  unusual  prevalence  of  disease. 

To  answer  this  question,  the  mortality  from  North,  Cen- 
tral, and  South  China  for  each  society  was  calculated. 

Within  each  society  we  may  expect  to  find  mortality  fairly 
constant,  the  geographical  location  being  the  variable  which 
should  modify  results.  Unfortunately,  division  into  such  small 
groups  reduces  the  numbers  below  the  point  where  great  reli- 
ance can  be  placed  on  them. 


The  Health  of  the  Children 


39 


Table  29      MORTALITY  OF  CHILDREN  BY  SOCIETIES.  AND  BY  SECTIONS  OF  CfflNA 


SOCIETY 

Section 

Total 
Number 
Living 
Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

krtf-  Rapt.  ,  North 

North 

Central 

South 

'63" 
36 

"h' 

1 

""e" 

1 

.... 

1 

"95" 

28 

'95" 
28 

63' 

28 

Am.  Meth.,  North 

North 

Central 

South 

66 
74 
67 

8 
5 
3 

7 
5 
3 

3 
3 
1 

121 
68 
53 

106 
68 
S3 

45 
41 

18 

London  Mission 

North 

Central 

South 

26 
26 
30 

1 

4 
2 

1 
3 
1 

0 
2 
1 

38 
154 
67 

38 
115 
33 

0 

77 

33 

Y.M.  C.A 

North 

Central 

South 

38 
61 
21 

4 

8 
0 

4 

7 
0 

2 
6 
0 

105 

131 

0 

105 

115 

0 

53 
98 

0 

Ch.  Misa.  Soc... 

North 

Central 

South 

"so" 

44 

"Y 

4 

""7" 
4 

""3" 
4 

140" 
91 

..  . 
140 
91 



60 

91 

Am.  Pres.,  North 

North 

Central 

South 

124 
122 
68 

14 
15 
9 

10 
12 

7 

5 
4 
5 

113 
123 
132 

80 
98 
104 

40 
33 

75 

Am.  Board 

North 

Central 

South 

92 
"46" 

17 
""§" 

14 
.... 

5 
.... 

185 
"65" 

152 
"22' 

54 

22 

Other  Am.  Soc 

North 

Central 

South 

110 

254 

74 

21 

23 

6 

14 

18 
6 

6 
8 
4 

199 
91 
81 

127 
71 
81 

55 
32 

54 

km.  Luth.  Societies-. 

North 

Central 

South 

82 
55 

7 
11 

6 
9 

2 
3 

85 
200 

73 
164 

24 
54 

Other  Eng.  Soc. 

North 

Central 

South 

141 
93 
56 

27 
13 
2 

23 
9 
2 

15 
3 
1 

191 
140 
36 

163 
97 
36 

106 
32 

19 

Other  European  Soc.    . 

North 

Central 

South 

75 
49 
47 

24 
6 
4 

21 
5 
4 

12 
4 

320 
123 
85 

240 
102 
85 

160 
82 

European  C.I.  M 

North 

Central 

South 

109 
32 

17 
5 

17 

5 

8 
2 

156 
156 

156 
156 

74 
62 

China  Inland  Mbsion .. 

North 

Central 

South 

164 

272 
12 

41 
39 

31 
26 

17 
15 

255 
143 

189 
96 

104 
54 

Am.  Bapt.,  South 

North 

Central 

South 

61 
41 

17 

13 
9 
5 

9 
8 
4 

5 
5 
3 

213 
219 
299 

144 
195 
235 

82 
122 

176 

In  nine  of  the  fourteen  societies  mortality  rates  decreased 
progressively  from  north  to  south.  In  four,  on  the  other 
hand,  they  increased.  In  one  (the  Y.  M.  C.  A.)  Central  China 
showed  higher  rates  than  either  North  or  South  China. 


40       The  Health  of  Missionary  Families  in   China 

From  this  analysis  we  can  conclude  that  geographical 
location  in  itself  helps  to  determine  mortality,  but  that  it  is 
not  the  only  factor  in  determining  the  death  rates  for  societies. 
It  should  be  remembered  that  many  societies  in  North  China, 
particularly  in  Shensi,  Manchuria  and  Mongolia,  are  doing 
difficult  pioneer  work.  In  all  frontier  communities,  death 
rates  among  children  are  high. 

In  later  tables  further  light  will  be  thrown  on  the  cause 
for  the  high  rates  in  North  China. 


Table  30 


SIZE  OF  SOCIETIES 

MORTALITY  OF  CHILDREN 
WITH  REFERENCE  TO  SIZE  OF  MISSIONARY  SOCIETIES 


Societies  Reporting 
Following  Number 

Number 

of  Living 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1  000  Living  Births 

of  Children 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

More  than  75  (13  societies) 

Between  20  and  75  (20  societies) 
Less  than  20  (60  societies) 

2,028 
753 
418 

275 
104 
67 

220 
86 
55 

121 
37 
34 

135 
138 
160 

108 
114 
131 

60 
50 
81 

Figure  13.  Mortality 
of  children  by  size 
of  missionary  soci- 
eties. (Illustrating 
Table  30.) 


As  seen  in  Table  30  and  Figure  13,  there 
is  little  difference  in  death  rates  for  soci- 
eties reporting  between  20  and  75  children, 
and  those  reporting  over  75.  The  rates  are 
increased,  however,  for  the  60  small  soci- 
eties reporting  less  than  20  children  apiece. 

NATIONALITY   OF   SOCIETIES 

In  Table  31  and  Figure  14  is  shown  the 
mortality  according  to  the  country  in  which 
the  head  office  of  the  society  is  located. 
"Great  Britain"  includes  Ireland,  Scotland 
and  Australia.  The  China  Inland  Mission 
is  classed  separately,  as  it  has  offices  in 
various  countries.  "Europe"  includes  the 
European  missions  associated  with  the 
China  Inland  Mission. 


The  Health  of  the  Children 


41 


Table  31 


MORTALITY  OF  CHILDREN  BY  NATIONALITY  OF  SOCIETIES 


MISSION  OFFICE 

Number 

of  Livinc 

Births 

Percent- 
ase  of 
Total 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

LOCATED  IN 

Total 

0-5 
Years 

0-1 
Year 

Totel 

0-5 
Years 

0-1 
Year 

America 

1,732 

4no 

209 
449 

55 
15 
6 
14 

216 
60 
29 
80 

173 
51 
26 
57 

90 
28 
15 
32 

122 
122 
139 
178 

97 
104 
124 
129 

51 
57 

Canada — 

(Ciiina  Inland) 

72 
71 

Total  outside  Europe — 

2,930 

90 

385 

307 

165 

131 

105 

56 

Europe 

310 

10 

66 

59 

31 

213 

190 

100 

Figure  14.     Mortality  of  children  by  uatioualicy  of  mission- 
ary societies.     (Illustrating  Table  31.) 


Table  32 


BIRTHPLACE   OF   PARENTS 

MORTALITY  OF  CHILDREN,  BY  BIRTHPLACE  OF  PARENTS 


PARENTS  BORN 

Total 
Number 
Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

Total 

Under  5 
Years 

Under  I 
Year 

Total 

Under  5 
Years 

Under  1 
Year 

1.  One -r  both  born  in  China.. 

2.  Both  born  in  United  States 

3.  Father  and  motlier  born  in 

176 
701 

311 

491 
218 

16 

84 

40 

71 

46 

12 

72 

31 

58 
39 

8 
37 

13 

31 
19 

100 
120 

129 

141 
212 

68 
100 

100 

118 
180 

45 
63 

42 

J  4.  Both  bom  in  Great  Britain 

1       or  Colonies 

5.  Both  born  in  Europe. 

63 
87 

Total 

1,897 

257 

205 

108 

125 

108 

67 

1,307 

191 

1,58 

88 

147 

121 

63 

42       The  Health  of  Missionary  Families  in   China 


Figure  15.     Mortality  of  children  by  birthplace 
of  parents.    (Illustrating  Table  32.) 


Table  32  and  Figure  15  show  the  mortality  of  children 
according  to  the  birthplace  of  parents.  The  group  with  the 
lowest  mortality  is  the  one  in  which  one  or  both  parents  were 
bom  in  China.  Is  this  because  of  acquired  resistance  to  dis- 
ease, or  because  of  better  knowledge  of  the  means  of  pre- 
vention ? 

In  this  table,  again,  children  of  continental  European 
parentage  show  the  highest  mortality.  This  tabulation  is 
incomplete,  because  in  two-fifths  of  the  questionnaires  the 
birthplace  of  parents  was  not  stated.  Children  of  parents  who 
did  not  fill  the  blanks  in  detail  show  a  higher  death  rate  than 
children  of  those  who  did.  This  would  seem  to  show  that 
those  who  are  most  interested  in  an  investigation  of  this  sort 
are  also  more  successful  in  preventing  sickness  and  death 
among  their  children. 


The  Health  of  the  Children 


43 


MEDICAL   TRAINING    OF    PARENTS 

Investigators  agree  that  an  important  factor  in  child  mor- 
tality is  the  intelligence  of  parents  concerning  medical  mat- 
ters. If  in  this  study,  children  of  doctors  and  nurses  have  a 
lower  mortality  than  others,  it  will  be  an  argument  for  more 
extensive  education  of  missionaries  in  matters  of  health.  If, 
on  the  other  hand,  they  do  not  show  a  distinctly  lower  mor- 
tality, not  much  can  be  hoped  for  from  this  quarter.  Table  33 
and  Figure  16  show  the  results  of  this  tabulation. 


Table  33 


MORTALTTY  OF  CHILDREN  BY  MEDICAL  TRAINING  OF  PARENTS 


Total 
Number 
Living 
Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

379 
252 
146 

47 
23 
11 

42 
21 

8 

25 
14 
4 

124 
91 
75 

111 

83 
54 

65 

Mother  a  doctor  or  nurse 

Both  parents  medically  trained 

65 
27 

Total.- -- 

777 

81 

71 

43 

104 

91 

56 

Neither  parent  medically  trsiaed 

2,427 

367 

292 

153 

151 

120 

63 

Figure    16.     Mortality    of   children    by    medical 
training  of  parents.  (Illustrating  Table  33.) 

The  education  of  the  mother  seems  to  have  greater  influ- 
ence than  that  of  the  father,  though  results  are  best  when  both 
are  trained.  This  would  indicate  that  home  sanitation  is  of 
more  importance  than  medical  treatment.  It  would  point  the 
particular  value,  also,  of  education  of  the  wife  in  hygiene  and 
the  elements  of  preventive  medicine.  Note  that  infant  mor- 
tality differs  but  little  between  the  trained  and  untrained. 


44       The  Health  of  Missionary  Families  in   China 

The  big  difference  comes  after  the  first  year.  Families  in 
which  both  parents  have  training  show  the  remarkably  low 
infant  mortality  rate  of  27. 

In  this  tabulation  only  those  parents  who  have  had  at  least  three-fourths 
of  medical  or  nursing  training  are  included  among  the  trained.  Thoee  with 
partial  training  were  too  small  a  class  to  make  calculation  of  the  mortality 
rate  of  value. 


Table  34 


MORTALITY  OF  CHILDREN  BY  MEDICAL  TRAINING  OF  PARENTS 
AND  BY  SECTIONS  OF  CHINA 


Total 

Number 

Born 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Livini?  Births 

SECTION 

Total 

Under  5 
Years 

Under  1 
Year 

Total 

Under  5 
Years 

Under! 
Year 

PARENTS  WITH  MEDICAL 

TRAINING 
North...             

209 
425 
134 

24 
49 
10 

20 
44 

8 

9 
27 

7 

115 
115 

75 

95 
103 
59 

43 

64 

South..    . 

52 

Total  with  Training 

PARENTS  WITHOUT  MEDI- 
CAL TRAINING 
North 

768 

743 

1,315 

372 

83 

154 
180 
32 

72 

122 
141 

28 

43 

65 
71 

17 

lOS 

205 
137 
86 

93 

162 
107 
75 

56 
86 

64 

South. 

45 

Total  without  Training. 

2,436 

366 

291 

153 

149 

119 

62 

Figure  17.     Mortality  of  children  by  medical  training  of 
parents  and  by  sections  of  China.     (Illustrating  Table  34.) 


The  Health  of  the   Children 


45 


This  good  showing  of  the  trained  does  not  mean  that  the 
doctors  and  nurses  are  concentrated  in  South  China.  Twenty- 
six  per  cent  of  their  children  are  in  North  China,  against  30 
per  cent  of  the  children  of  those  without  training. 

Table  34  and  Figure  17  show  that  for  each  section  of 
China  the  children  of  the  medically  trained  have  a  lower  mor- 
tality. (One  exception  is  the  high  infant  mortality  among  the 
trained  of  Central  China.)  The  matter  of  medical  training 
is  not,  however,  the  only  factor,  for  the  trained  in  North  China 
have  a  higher  rate  than  the  untrained  in  South  China. 


Tablets 


MORTALITY  OF  CHILDREN  BY  MEDICAL  TRAINING  OF  PARENTS  AND 
BY  GROUPS  OF  SOCIETIES 


Total 
Number 
of  Living 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

SOCIETIES 

Total 

0-5 

Years 

0-1 

Year 

Total 

0-5 
Years 

0-1 

Year 

PARENTS  WITH  MEDICAL 
TRAINING 

273 
237 
267 

21 
26 
34 

20 
24 
27 

10 
14 
19 

76 
109 
127 

73 
101 
101 

36 

59 

Third  Group 

71 

Tota!  with  Training  ...- 

777 

81 

71 

43 

104 

91 

56 

PARENTS  WITHOUT  MEDI- 
CAL TRAINING 

777 

678 

1,008 

80 
92 
199 

63 
74 
158 

36 
33 

S4 

115 
1,35 
197 

81 
109 
156 

46 

48 

Third  Group 

83 

Total  without  Training- 

2,463 

371 

295 

153 

150 

119 

61 

The  good  showing  of  the  medically  trained  is  in  spite  of 
the  fact  that  doctors  more  than  missionaries  in  other  types  of 
work  have  been  used  in  pioneer  work,  located  in  inland  sta- 
tions where  mortality  rates  would  naturally  be  high.  The 
same  is  not  necessarily  true  of  wives  who  are  doctors  or 
nurses  (this  may  be  one  reason  for  the  lower  rates  of  these 
families  in  contrast  with  the  families  in  which  the  husband  is 
a  doctor),  but  medically  trained  wives  are  usually  called  on 
for  heavy  work  outside  the  home. 


46       The  Health  of  Missionary  Families  in   China 


Figure  18.     Mortality  of  children  by  medical  training  of 
parents  and  by  groups  of  societies.     (Illustrating  Table  35.) 


In  Table  35  and  Figure  18  the  figures  are  reclassified 
into  groups  of  societies.  Here  the  same  result  is  obtained. 
The  trained  in  each  group  make  a  better  showing  than  the 
untrained  (except  for  the  infants  of  the  middle  group),  but 
the  untrained  of  the  first  group  have  a  lower  rate  than  the 
trained  of  the  third  group.  (For  the  societies  comprising 
each  group,  see  Table  26.) 

RATIO    OF  DOCTORS    TO    THE    MISSION    FORCE 

A  corollary  of  the  preceding  discussion  is  the  question  of 
the  ratio  of  doctors  to  the  missionary  force.  Table  36  gives 
the  percentage  of  doctors  among  the  25  largest  societies.  The 
figures  do  not  include  children.  The  issue  is  not  clear-cut, 
for  certain  societies,  e.g.,  the  Y.  M.  C.  A.,  are  in  cities  where 
community  or  doctors  of  other  missions  are  available.  In 
the  table  the  order  of  societies  follows  the  order  of  total  mor- 
tality of  children,  those  with  the  lowest  at  the  top.  Five  of 
the  seven  lower  societies  (71%)  have  less  than  the  average 
percentage  of  doctors,  while  only  three  of  the  nine  upper  soci- 
eties (33%)  have  less  than  the  average  percentage  (6.1%). 


The  Health  of  the  Children 


M 


The  ratio  given  in  the  table  for  some  of  the  English  and  Cana- 
dian societies  is  abnormally  low  because  of  the  enlistment  of 
some  of  their  doctors  in  the  war. 

It  would  be  of  interest  to  know  what  percentage  of  sta^ 
tions  are  without  doctors,  also  how  many  foreigners  each  mis- 
sion doctor  has  dependent  on  him. 


Table  36 


PERCENTAGE  OF  PHYSICIANS  TO  THE  TOTAL  ADULT  MISSIONARY 
FORCE  BY  SOCIETIES 


SOCIETIES* 

Total  Foreign  Force 
(Adult) 

Number  Physicians 
(Men  and  Women) 

Percentage  of 
Physicians 

138 

14 

10.3 

American  Church  Misaiona . 

204 

12 

5.8 

American  Methodist,  North  ..... 

363 

22 

6.1 

149 

16 

10.7 

Y.  M.C.  A. 

175 

467 

13 

2.8 

Canadian  Methodist 

178 

13 

7.3 

Church  Missionary  Society  .. 

316 

20 

6.6 

467 

49 

10.5 

77 

3 

4. 

166 

8 

4.8 

Other  English  Societies  .             .          . 

319 

66 

2.1 

940 

13 

1.3 

142 

16 

11.2 

Other  European  Societies  ..  ..  

184 

5 

2.7 

153 

11 

7.1 

Total - 

4,436 

273 

6.1 

♦Figures  are  taken  from  the  China  Mission  Year  Book  (1918)  and  include  only  the  25  largest  societies. 


RECENT   AND    REMOTE   PERIODS 

We  look  to  the  future.  We  are  not  particularly  concerned 
about  death  rates  of  several  decades  ago.  It  is  pertinent  to 
inquire,  therefore,  (1)  what  proportion  of  the  children  of  this 
study  belong  to  recent  times;  (2)  whether  death  rates  of  chil- 
dren have  been  decreasing  at  equal  pace  with  the  decrease  in 
rates  in  England  and  America. 

In  order  to  answer  these  questions,  all  blanks  were  tabu- 
lated with  respect  to  the  number  of  years  parents  have  been 
married. 

Only  a  few  reports  were  received  concerning  families  not 
now  on  the  field,  so  that  practically  all  the  subjects  of  this 


48       The  Health  of  Missionary  Families  in   China 


study  are  the  children  of  missionaries  who  are  now  active 
missionaries.  Of  the  3,126  children,  whose  parents'  years 
of  marriage  are  recorded,  the  parents  of  31%  were  married 
less  than  10  years  ago,  70%  less  than  20  years  ago,  and  92% 
less  than  30  years  ago.  Of  the  2,623  living  children,  whose 
ages  are  recorded,  only  51%  are  more  than  9  years  old,  15% 
more  than  19  years,  and  3%  more  than  29  years  (Table  16). 
The  average  age  of  all  children  is  8.6  years.  This  study,  then, 
deals  in  the  main  v/ith  a  recent  period  of  missionary  work. 

Table  37  gives  the  mortality  for  four  periods.  A  source 
of  error  should  be  noted.  Classification  is  based  on  the  num- 
ber of  years  married,  rather  than  on  the  number  of  years  ago 
married.  In  the  cases  in  which  a  parent  had  died,  the  children 
are  counted  as  born  more  recently  than  they  were  born.  This 
error  would  tend  to  increase  rates  slightly  for  the  more  recent 
periods.  In  Table  38  only  the  0-1  and  0-5  year  groups  are  of 
value.  Deaths  after  five  years  of  age  are  naturally  increased 
in  the  older  families  because  the  children  are  older. 


Table  37 


MORTALITY  OF  CHILDREN  BY  LENGTH  OF  TIME  PARENTS  HAVE 
BEEN  MARRIED 


Number  of 

Total 
Living 
Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

Tears  Wliich 
Pareats  Have 
Been    Married 

Total 

0-5 

Years 

0-1 
Year 

Total 

p-5 
Years 

0-1 
Year 

0-9 

9S6 

1,219 

672 

249 

89 

92 
151 
132 

58 
8 

90 
129 
100 

34 
7 

4S 
76 
47 
14 
6 

93 
123 

182 

233 

90 

91 

106 
149 
136 

79 

49 

10-19 

62 

l(>-29 

70 

80  and  oyer 

Years  not  stated 

56 
67 

If  we  divide  the  children  into  two  groups,  the  first  group 
comprising  those  whose  parents  have  been  married  less  than 
20  years,  the  second  group  those  whose  parents  have  been 
married  more  than  20  years,  and  if  we  count  the  deaths  for 
the  first  group  by  adding  the  number  of  children  at  present 
living,  but  who  will  die  before  completing  the  first  or  the  fifth 
year,  we  get  the  following  figures :  Infant  mortality,  first 
group  58,  second  group  66.  Mortality  under  5  years,  first 
group  120,  second  group  145.  This  means  a  reduction  of  mor- 
tality between  the  two  groups  {i.e.,  in  the  10-15  years  which 
separates  the  two)  of  12%  in  infant  mortality  and  18%  in 
mortality  under  five  years. 

Because  of  the  round-about  method  of  arriving  at  the 
above  figures,  comparison  with  government  statistics  must 
be  far  from  accurate. 


The  Health  of  the  Children 


49 


Between  the  years  1900  and  1911  infant  mortality  in  the 
United  States"  was  reduced  22%,  and  mortality  under  five 
years  27%.  In  England,^^  during  the  40-year  period  ending; 
1911-15,  mortality  was  reduced  as  follows :  for  the  first  year 
of  life,  about  30%  ;  for  the  second  year,  a  little  over  40%  ;  for 
the  third,  fourth,  and  fifth  years,  about  50%. 


Table  38 


MORTALITY  AMONG  FIRST  AND  SECOND  BORN  CHILDREN  BY  NUMBER 
OF  YEASS  PARENTS  HAVE  BEEN  MARRIED 


Number 

Number 

of  Living 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

of  Years 
Married 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

0-9 

815 
679 
313 
106 

79 
94 
70 
27 

77 
76 
45 
13 

38 
47 
21 
10 

97 
138 
227 
225 

94 
112 
144 
169 

47 

10-19 

69 

20-29     

67 

30  or  more 

94 

In  Table  38,  as  illustrated  in  Figure 
19,  only  first  and  second  births  in  each 
marriage  period  are  counted.  In  this 
way  the  births  are  more  sharply  con- 
fined within  the  various  periods.  The 
difference  in  mortality  for  the  0-1  and 
0-5  age  periods  of  these  first  and  sec- 
ond-born children  is  greater  than 
when  all  children  are  counted.  The 
difference  is  due  largely  to  the  very 
low  mortality  of  third  and  later  bom 
children  among  those  married  more 
than  30  years.  These  143  children 
show  an  infant  mortality  of  only  21. 
Is  this  a  case  of  survival  of  the  fittest 
or  of  acquired  immunity? 

In  Table  38  mortality  of  children  of 
the  first  group  (parents  married  less 
than  20  years)  show,  for  infants,  25%, 
and  for  children  under  five,  32%  improvement  over  the  second 
group  (parents  married  more  than  20  years).  These  figures 
would  be  slightly  less  if  corrected  for  the  first  and  second 
bom  living  children  under  five  and  one  who  will  die  before 
reaching  those  ages. 


Figure  19.  Mortality  of 
first  and  second  born 
children  by  number  of 
years  parents  have 
been  married.  (Illus- 
trating Table  38.) 


50       The  Health   of  Missionary   Families  in   China 

The  study  of  this  phase  shows  that  there  has  been  a  reduc- 
tion of  child  mortality  among  missionary  children  in  recent 
years.  It  is  doubtful,  however,  if  this  is  greater  than  the 
reduction  which  has  taken  place  among  the  general  population 
of  civilized  countries  during  the  same  period.  Probably  the 
reduction  would  be  greater  if  we  had  figures  for  children  of 
the  entire  previous  generation  of  missionaries.  The  families 
now  on  the  field  have  demonstrated  their  abilitv  to  survive. 


Table  39 


ORDER   OF   BIRTH 

MORTALITY  OF  CHILDREN  BY  ORDER  OF  BIRTH 


Ordw 

Total 
Number 
of  Livina 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

of  Birth 

Total 

0-5 
Yean 

0-1 
Year 

Tctal 

0-5 
Years 

0-1 
Year 

lat   bom 
and      " 
3rd      " 
4th      " 
5th      " 
6th  and  more.  - 

1,122 
854 
569 
340 
17S 
152 

158 
117 
72 
42 
22 
30 

130 
90 
62 
32 
19 
27 

70 
49 
30 
20 
10 
12 

141 
137 
127 
124 
123 
197 

115 
105 
108 
94 

100 
177 

62 
57 
53 
58 
56 
79 

Total 

3,215 

441 

360 

191 

137 

112 

59 

In  Table  39  and  Figure  20 
is  sho\sTi  the  mortality  of 
children  by  the  order  of  birth. 
There  is  a  slight  do^vnward 
tendency  of  all  age  groups 
until  after  the  fifth  child, 
when  all  rates  leap  upward. 
This  rise  is  due  entirely  to 
increase  in  deaths  among 
children  under  5  years.  The 
cause  for  this,  in  part  at 
least,  is  shown  in  Figure  28, 
second  column. 


figure  20.  Mortality  of  children  by 
order  of  birth.  (Illustrating  Ta- 
ble 39.) 


The  Health  of  the  Children 


51 


NUMBER   OF   CHILDREN   IN   FAMILY 

Table  40       MORTALITY  OF  CHILDREN  BY  NUMBER  OF  CHILDREN  IN  FAMILY 


Number  of 

Children 

Total 

Number  of 

Living 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Living  Births 

in  Family 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

1 

264 

380 

689 

625 

490 

252 

74 

72 

63 

62 

20 
50 
96 
99 
66 
51 
21 
11 
18 
18 

19 
40 
80 
81 
48 
45 
16 
8 
15 

18 
19 
41 
42 
27 
23 
10 
4 
6 

75 
132 
139 
158 
135 
202 
284 
153 
286 
290 

70 
105 
116 
130 

98 
179 
216 
111 
233 
226 

60 

2 

8 

50 
60 

4.. 

67 

5  . 

55 

6 

93 

7 

135 

8..  .      . 

56 

9 

95 

10.11.12 

14                      6 

97 

Total 

3,229 

450 

66                  194 

139 

113 

60 

Figure  21.  Mortality  of  children  by  num- 
ber of  children  in  the  family.  (Illus- 
trating Table  40.) 


Table  40  and  Figure 
21  show  mortality  ac- 
cording to  the  size  of 
the  family.  Infant  mor- 
tality remains  fairly 
constant  until  families 
having  more  than  five 
children  are  reached. 
Mortality  of  other  chil- 
dren, however,  increases 
progressively,  as  the 
family  increases  in  size. 
A  curious  fact  is  the 
relatively  low  mortality 
in  families  where  there 
are  five  children. 

The  increase  of  rate 
for  large  families  is  due 
in  part  to  the  fact  that 
the  children  are  older. 


52       The  Health  of  Missionary  Families  in   China 


Table  41 


BIRTHPLACE    OF    CHILDREN 

MORTALITY  OF  CHILDREN  BY  BIRTHPLACE 


Number 

of  Living 

Births 

Number  of  Deaths 

Number  of  Deaths  Per 
1,000  Livinj;  Births 

BIRTHPLACE 

Total 

0-5 
Years 

0-1 
Year 

Total 

0-5 
Years 

0-1 
Year 

Outside  of  China 

385 

49 

40 

20 

128 

104 

52 

In  China 

2,819* 

399 

325 

174 

141 

115 

62 

^Includes  a  few  children  whose  place  of  birth  was  not  stated. 


Figure  22.    Mortality  of 

children  by  birthplace. 

(Illustrating  Table  41.) 


Among  missionaries  one  often  hears 
discussions  concerning  the  relative 
health  of  children  born  in  China  and 
those  born  at  home.  Table  41  shows  that 
there  is  no  great  difference  of  mortality 
in  the  two  groups.  The  advantage  for 
those  bom  outside  China  is  14%  for  the 
first  year  and  10%  for  the  rest  of  life. 
Children  born  outside  China  have  spent 
58%  of  their  life  in  China,  while  all  chil- 
dren have  spent  67%. 

The  following  is  the  list  of  birthplaces  of  chil- 
dren born  outside  of  China:  United  States,  191; 
England  and  Wales,  53;  Canada,  28;  Scotland,  15; 
Sweden,  12;  Australia  and  New  Zealand,  11;  Ger- 
many, 10;  Norway  and  Finland,  6;  Ireland,  ;'. ; 
miscellaneous,  56;  total,  385.  Percentage  of  chil- 
dren born  in  China,  87.5;  percentage  of  married 
life  spent  in  China,  81.0. 


OTHER   FACTORS   OF   CHILD   MORTALITY 

It  was  realized  that  the  more  questions  asked  in  the  ques- 
tionnaire, the  fewer  would  be  the  answers.  Therefore,  sev- 
eral important  factors  not  included  in  the  statistical  study 
should  be  mentioned. 

Salaries — As  a  rule,  curves  of  child  mortality  closely  par- 
allel the  curves  representing  family  income,  i.e.,  the  lower  the 
wages,  the  higher  the  number  of  deaths.  It  is  likely  that 
where  missionary  salaries  are  insufficient  to  provide  summer 
vacations,  the  best  milk  available,  medical  overhauling  on  fur- 
lough, etc.,  deaths  will  result.  Though  exact  information  has 
not  been  obtained,  the  writer  thinks  that  the  average  salary 
paid  by  societies  in  the  lower  half  of  Table  26  is  less  than  that 


The  Health  of  the  Children 53 

paid  by  societies  in  the  upper  half.  One  parent  in  the  former 
group  writes,  '^How  can  I  bring  up  and  educate  my  children 
on  a  salary  of  (the  equivalent  of)  G  $400  a  year?"  However, 
such  a  cry  was  found  in  the  letters  but  rarely.  Information 
as  to  whether  there  is  waste  of  life  and  efficiency  because  of 
sub-living  salaries  would  be  hard  to  secure  from  the  mission- 
aries directly. 

Amahs.  ''The  environment  of  the  infant,"  says  Sir  George 
Newman,^^  "is  its  mother."  "The  problem  of  infant  mor- 
tality is  not  one  of  sanitation  alone,  of  housing,  or  indeed  of 
poverty  as  such,  but  is  mainly  a  question  of  motherhood."^* 
Another  says,  "The  most  important  factors  in  infant  mortal- 
ity are  the  strength,  the  health,  the  character  and  the  intelli- 
gence of  the  mother. "-°  An  extremely  pertinent  question  is, 
"What  is  the  effect  on  child  mortality  in  China  of  the  substi- 
tution of  hired  nursehood  for  motherhood,  of  the  substitution 
of  the  'health,  the  character  and  the  intelligence'  of  a  Chi- 
nese servant  woman  for  the  'health,  the  character  and  the 
intelligence'  of  the  missionary  mother?  If  children  are  deliv- 
ered entirely  into  the  keeping  of  servant  Chinese,  we  cannot 
expect  a  mortality  a  great  deal  lower  than  that  for  the  Chinese 
children,  as  shown  in  Figure  1. 

There  is  naturally  a  wide  difference  of  opinion  as  to  how 
much  the  personal  care  of  children  should  be  subordinated  to 
the  prosecution  of  mission  work.  One  mother  takes  her  small 
children  with  her  on  country  trips  purely  as  a  bait  for  attract- 
ing crowds.  Though  these  statistics  do  not  permit  analysis  of 
the  part  care  and  feeding  of  the  children  by  amahs  plays  in 
child  mortality,  a  number  of  the  correspondents  deal  with  the 
point  and  make  it  clear  that  they  consider  it  an  important  fac- 
tor in  mortality  of  missionary  children  in  China. 

Kitchens — A  third  of  all  deaths  of  these  children  were 
due  to  intestinal  infections ;  dysentery,  diarrhoea,  cholera,  and 
tjrphoid  fever.  This  points  to  the  enormous  importance  of  the 
kitchen  in  the  life,  or  death,  of  missionary  children.  Many 
kitchens  in  North  China  are  dark,  dirty,  and  fly-infested,  used 
by  all  the  servants,  the  government  an  absolute  monarchy 
with  the  native  cook  on  the  throne ;  in  short,  a  favorable  port 
of  embarkation  for  all  germs  bound  intestineward. 

The  importance  of  breast-feeding  and  medical  care  have 
been  mentioned.  Other  factors  which  can  be  only  named  are : 
milk  and  water  supply,  location  in  the  city  or  country,  method 
of  sewage  disposal,  summer  vacations,  location  of  schools,  etc. 


54       The  Health  of  Missionary  Families  in   China 


THE  CAUSE  OF  DEATH,  BY  GROUPS  OF  DISEASES 

Besides  knowing  the  proportion  of  children  dying,  it  is 
important  from  the  side  of  prevention  that  we  know  the  causes 
of  death.  For  purposes  of  comparison,  all  causes  of  deaths 
are  divided  into  ten  groups.  By  this  means  we  diminish  the 
error  from  using  small  numbers  and  from  inexact  diagnoses. 

The  groups  used  are  as  follows:  (1)  dysentery  ("with  blood  and 
mucus"  specified  on  question  blank),  both  acute  and  chronic.  (2)  Intestinal 
infections  aside  from  dysentery  and  typhoid  fever,  Including  diarrhcea,  colitis, 
cholera  infantum,  Asiatic  cholera,  enteritis.  (3)  Respiratory  infections — 
bronchitis,  pneumonia,  and  whooping  cough.  (4)  Smallpox.  (5)  Six 
major  infections,  viz.,  diphtheria,  scarlet  fever,  typhoid  fever,  tuberculosis, 
malaria  and  meningitis.  (6)  Birth  defect  and  injury,  difficult  labor, 
eclampsia,  malformation,  etc.  (7)  Prematurity.  (8)  Malnutrition,  difficult 
feeding.  (9)  All  other  causes,  and  (10)  cause  unknown,  not  stated  or  unin- 
telligibly stated. 


Table  42 


GEOGRAPHICAL   LOCATION 

MORTALITY  FROM  VARIOUS  DISEASES  BY  SECTIONS  OF  CHINA 


Total 

Number  of  Deaths  Per  1,000  Living  Births  From  Specified  Causes 

a 

□ 

u, 

Z 

1 
5 

SECTION  OF  CHINA 

Number 

o 

° 

■3 

Li\'ing 
Births 

t 

J3 
g 

S 

g 

S  „ 

8 

£ 

3 

o 

03 

O 

3 

fc 

& 

O  o 

:S"c 

a 

^ 

o 

a 

h 

Q 

^ 

a 

CO 

■& 

H 

(X, 

S 

< 

6 

North 

95S 

1,740 

506 

32 
21 
9 

19 
17 

1 

22 
14 

1 

9 
6 

38 
25 
19 

8 
7 
5 

7 
5 
3 

5 
4 

7 

29 
19 
16 

11 

Central 

10 

South 

7 

Figure  23.     Mortality  of  children  from  various  causes  by  sections 
of  China.     (Illustrating  Table  42.) 


Tables  42-49  give  the  number  of  deaths  for  all  ages  per 
1,000  children  born.  Table  42  and  Figure  23  show  why  death 
rates  decrease  from  North  China  to  South  China.  Every 
disease  group  with  the  single  exception  of  ''malnutrition" 


The  Health  of  the  Children  55 

shows  this  downward  curve.  The  sharpness  of  the  descent  is 
most  marked  for  the  intestinal,  respiratory  and  smallpox 
groups,  and  less  marked  for  the  major  infectious  group. 

The  figures  show  strikingly  the  disproportionate  impor- 
tance of  infections  over  constitutional  causes  of  death  in  North 
China.  If  we  add  the  first  five  groups  embracing  the  infec- 
tious (bacterial)  diseases,  and  take  the  ratio  for  North  China 
as  the  index,  Central  China  shows  39%  and  South  China 
only  14%  of  the  deaths  which  North  China  records.  Now  if 
we  combine  the  next  three  groups — which  gives  the  deaths  for 
nutritional,  developmental  and  birth  causes — we  find  that 
Central  China  has  80%  and  South  China  75%  of  the  rate  for 
North  China. 

In  other  words,  as  a  cause  of  death  these  non-infectious 
conditions  are,  in  relation  to  North  China  as  a  standard,  two 
times  more  important  in  Central  China  and  five  times  more 
important  in  South  China  than  the  infectious  diseases. 

MISSIONARY   SOCIETIES 

Some  of  the  external  factors  which  influence  mortality 
rates  in  societies  (i.  e.,  age  of  children,  number  in  family,  per- 
centage of  time  in  China,  geographical  distribution  of  work- 
ers, proportion  of  doctors)  have  been  considered.  Other  even 
more  important  factors  are  internal  to  the  societies,  having 
to  do  with  the  policy  of  the  boards  towards  the  selection  of 
workers  and  subsequent  care  of  them.  There  is  no  attempt 
in  this  paper  to  relate  mortality  rates  of  individual  societies 
to  these  internal  factors.  This  can  be  done  best  by  members 
of  the  various  societies. 

It  is  important,  however,  that  this  study  help  show  soci- 
eties from  what  quarters  death  has  come  in  the  past.  This  is 
attempted  in  Table  43.  Division  of  the  statistics  into  so  many 
groups  diminishes  the  reliability  of  results,  soi  that  only 
marked  differences  from  the  average  should  attract  attention. 


56       The  Health   of  Missionary  Families  in   China 


Table  43  MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES,  BY  SOCIETIES 


Total 

Number 

of  Living 

Births 

Number  of  Deaths  Per  1,000  Living  Births  From  Specified  Causes 

SOCIETY 

1 

"o 

t 

3 

1 
1 

a 

1 

J 

o 

h 

pa 

1 

1 

"3 

1 
o 

& 
■S 
o 

< 

1 
S 
CO 

o 

1 
o 

Am.  Bapt.,  North_ 

99 

10 

10 

20 

20 

10 

78 

26 

13 

13 

13 

13 

Am.  Meth.,  North 

197 

20 

5 

15 

5 

10 

10 

15 

82 

12 

12 

60 

Y.  M.  C.  A. 

120 

17 

17 

8 

8 

8 

17 

25 

437 

16 

9 

18 

7 

25 

2 

7 

2 

16 

9 

1,013 

16 

10 

14 

4 

18 

3 

7 

4 

16 

5 

Canadian  Meth 

134 

30 

7 

15 

7 

7 

7 

7 

15 

15 

94 

11 

21 

32 

11 

32 

11 

Am.  Presb.,  North 

314 

22 

6 

9 

6 

18 

6 

9 

6 

26 

6 

137 

21 

7 

7 

21 

14 

14 

42 

13S 

43 

7 

7 

36 

7 

36 

7 

98 

20 

20 

20 

20 

20 

20 

20 

20 

915 

24 

8 

12 

5 

20 

6 

6 

4 

24 

15 

Other  Eng.  Sec 

291 

34 

7 

10 

7 

31 

7 

7 

34 

China  Inland  Mis 

449 

22 

9 

22 

4 

40 

4 

4 

7 

29 

22 

Am.  Presb.,  South. 

106 

56 

19 

56 

28 

9 

9 

9 

Other  European  Soo 

171 

40 

18 

29 

18 

23 

6 

6 

40 

12 

Am.  Baptist,  South 

119 

25 

33 

8 

75 

17 

17 

42 

17 

European  C.  I.  M _ 

139 

43 

72 

14 

22 

43 

29 

7 

1 

Total — 3rd  group 

1,275 

28 

26 

18 

6 

40 

5 

4 

4 

31          12 

All  Societies  - 

3,203 

23 

15 

15 

6 

28 

5 

6 

4 

24         11 

1 

The  Health  of  the  Children 


57 


Figure  24.  Mortality  of  children  from  various  causes  by  societies. 
The  societies  are  in  the  order  of  total  mortality,  as  in  Figures 
11  and  12.     (Illustrating  Table  43.) 


Table  43  gives  the  deaths  from  various  causes  by  soci- 
eties. Figure  24  shows  the  relative  number  of  deaths  from 
four  of  the  groups  of  diseases.  Here,  as  in  Table  42,  the 
striking  difference  is  between  the  infectious  and  constitutional 
causes.  Societies  which  are  near  the  bottom  of  the  list  are 
there  because  of  the  six  major  and  the  intestinal  infectious 
diseases.  There  is  little  difference  between  the  first  and  third 
groups  of  societies  in  respiratory  infections,  and  practically 
no  difference  in  the  deaths  connected  with  birth  and  nutrition. 
Three  of  the  society  groups  show  relatively  twice  as  many 
deaths  from  smallpox  as  all  other  societies  combined. 


58       The  Health   of  Missionary  Families  in   China 


NATIONALITY    OF    SOCIETIES 

Table  44  MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES  BY  NATIONALITY 

OF  MISSIONARY  SOCIETIES 


Total 

Number  of  Deaths  Per  1,000  Births  From  Specified  Causes 

C3 

3 

-o 

SOCIETIES  WITH 

Number 

o 

3 

a 

•HEAD  OFFICES  IN 

of  Living 

o 

>> 

■g 

o 

o 

o 

CQ 

- 

Births 

>> 

S 

g 

M  a 

?^b 

s 

'S 

l~> 

o 

fc 

A 

o 

5'a 

a 

a 

o 

Q 

■q 

fS 

a 

CO 

s 

m 

£ 

S 

^ 

1,662 
776 

21 
21 

14 
9 

13 
11 

5 

2 

27 
20 

6 

8 

5 
1 

5 

1 

19 

28 

1 

Great  Britain  and  Canada. 

6 

(China  Inland) 

449 
310 

22 
42 

9 
42 

22 
22 

4 
19 

40 
32 

4 

4 
3 

7 
3 

29 
35 

22 

10 

Figure  25.     Mortality  of  children  from  various  causes  by  nationality  of 
missionary  societies.     (Illustrating  part  of  Table  44.) 


Table  44  and  Figure  25  show  the  causes  of  deaths  by 
nationality  of  societies.  American  and  English  (including 
colonial)  societies  show  no  significant  differences  in  causes 
of  death.  The  China  Inland  group  (which  is  mostly  English 
and  American)  shows  an  increase  in  respiratory  and  major 
infections.  The  European  societies  (which  include  those  asso- 
ciated with  the  C.  I.  M.)  show  greatest  increase  in  the  intes- 
tinal infections,  in  smallpox,  and  in  miscellaneous  causes. 


The  Health  of  the  Children 


59 


BIRTHPLACE   OF    PARENTS 

Table  45         MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES  BY  BIRTHPLACE  OF  PARENTS 


Total 

Number  of  Deaths  Per  1,000  Births  From  Specified  Causes 

a 

^ 

^ 

TJ 

BIRTHPLACE 
OF  PARENTS 

Number 
of  Living 

-a 
O 

>. 

a 

S 

3 
OS 

O 

5 

Births 

5 

"S 

g 

_o 

Q& 

3 

•E 

te 

o 

.t! 

3 

g 

s 

a. 

^  2 

"5  a 

a 

s 

o 

3 

>> 

Q 

i3 

1 

CO 

CP 

£ 

2 

< 

One  or  both  born  in  China  . . 

176 

28 

5 

11 

39 

11 

5 

17 

Both  born  in  Europe 

218 

50 

22 

36 

32 

36 

4 

4 

36 

18 

All  others  where  both  stated 

1,503 

18 

18 

15 

5 

28 

8    • 

6 

4 

15 

6 

Total  al'  societies 

3,203 

23 

15 

15 

6 

28 

5 

6 

4 

24 

11 

Table  45  is  deficient  because  for  more  than  one-half  of 
the  children  the  birthplace  of  parents  was  not  recorded.  Un- 
fortunately for  the  accuracy  of  the  computation,  the  number 
of  children  with  a  parent  bom  in  China  is  small.  These  chil- 
dren have  no  deaths  from  smallpox  or  malnutrition,  and  rela- 
tively few  from  diarrhoea. 

Of  all  the  children  whose  parents  were  bom  in  Europe 
5%  have  died  of  dysentery  and  more  than  3%  of  smallpox. 
Of  the  children  who  have  died,  15%  have  died  of  smallpox. 


MEDICAL   TRAINING   OF    PARENTS 

Table  4ft  MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES  BY  MEDICAL 

TRAINING  OF  PARENTS 


Total 
Number 
of  Living 

Births 

Number  Deaths  Per  1,000  Living  Births  From  Specified  Causes 

MEDICAL  TRAINING 
OF  PARENTS 

1 

3 

Q 

a 
"o 
O 

i 

5 

>> 

1 

o. 

"a 

a 

a 

o  a 
"3.2 

■r 

11 

"a 

a 
.2 

1 

i 

o 

1 

o 
< 

s 

"o 
CO 

Father  a  doctor 

379 
252 
146 

24 
16 
27 

19 
12 

7 

19 
12 

21 

8 
7 

10 
16 

7 

21 
12 
20 

10 

Mother  a  doctor  or  nurse... 

...... 

8 

7 

12 

Total ...  . 

777 

22 

14 

13 

14 

11 

1 

4 

18 

8 

Neither   parent   medically 
trained.. 

2,463 

23 

16 

16 

8 

32 

7 

7 

5 

23 

11 

60       The  Health   of  Missionary  Families  in   China 


Figure  26.     Mortality  of  children  from  various  causes  by  medical 
training  of  parents.     (Illustrating  part  of  Table  46.) 


We  turn  with  interest  to  the  cause  of  death  among  the 
medically  trained,  shown  in  Table  46  and  Figure  26.  As  be- 
tween father  and  mother  who  are  trained,  we  are  prepared  to 
find  as  we  do,  that  intestinal  infections  are  less  in  the  families 
in  which  the  trained  mother  has  charge  of  the  kitchen.  Even 
more  marked,  however,  is  the  reduction  in  deaths  from  major 
infections.  Presumably  this  is  not  because  the  doctor-wife  or 
nurse-wife  is  better  in  curing  disease,  but  because  she  is  more 
successful  in  preventing  infection. 

Comparing  the  last  two  lines  of  the  table  we  see  that  the 
children  of  the  medically  trained  have  suffered  less  than  the 
untrained  from  the  major  (mostly  air-borne)  infections  and 
less  from  pre-maturity  (presumably  because  of  better  pre- 
natal care).    No  children  of  this  class  have  died  of  smallpox. 

It  is  disappointing  to  find  that  children  of  the  trained  die 
from  intestinal  infections  almost  as  frequently  as  children  of 
the  untrained. 

RECENT   AND   REMOTE   PERIODS 

Table  47  MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES  BY  NUMBER  OF 

YEARS  PARENTS  HAVE  BEEN  MARRIED 


Number  of  Deaths  Per  1,000  Living  Births  From  specified  Causes 

NUMBER  OF  YEARS 

Total 

c« 

ll 

i 

3 

-o 

PARENTS  HAVE 
BEEN  MARRIED 

Number 
of  Living 

b 

9 

£ 

•1 

6 

CD 

Births 

-g 

^ 

^ 

D. 

's.2 

Q'a 

rt 

3 

•Z 

g 

t 

o. 

03 

s  s 

■s-^ 

a 

o 

§ 

Q 

5 

« 

CC 

■^'" 

^^ 

£ 

:s 

< 

0-9 

986 

21 

8 

8 

3 

14 

9 

8 

5 

10 

5 

10-19 

1,209 

2T 

16 

16 

7 

23 

9 

5 

5 

16 

11 

20-29 

672 

27 

25 

27 

12 

50 

6 

6 

1 

36 

9 

30plua.- 

249 

32 

28 

16 

4 

44 

28 

60 

32 

The  Health  of  the  Children 


61 


Figure  27.     Mortality  of  children  from  various  causes  by  number  of 
years  parents  have  been  married.  (Illustrating  part  of  Table  47.) 


In  Table  47,  all  groups,  except  those  associated  with  birth, 
show  diminished  deaths  for  families  married  the  shortest 
length  of  time.  As  this  is  for  deaths  at  all  ages,  naturally 
the  younger  families  have  had  fewer  deaths.  The  percentage 
reduction  from  the  highest  to  lowest  rate  is  60%.  Dysentery 
has  shown  less  than  the  average  reduction  (34%).  Deaths 
connected  with  birth  have  increased  in  the  younger  families 
rather  than  diminished.  All  other  groups  show  a  large  reduc- 
tion in  the  younger  families  of  from  70%  to  87%. 


ORDER   OF   BIRTH 

Table  48    MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES  BY  ORDER  OF  BIRTH 


Total 

Number  of  Deaths  Per  1,000  Living  Births  From  Specified  Causes 

C8 

-o 

S 

•o 

ORDER  OF  BIRTH 

No.  Living 

m 

I 

« 

Births 

% 

1 

o 

o  a 
"S  ° 

ll 

3 

.2 

o 
'S. 

CO 

o 

a 

.tj 

c« 

3 

S3 

& 

ca 

^  s 

■2'a 

S 

o 

3 

Q 

(3 

u 

tf 

^ 

CO 

m 

fi 

S 

< 

1,122 
854 
569 
518 
151 

25 
25 
33 
15 
20 

12 
21 
19 
6 
33 

14 
13 
12 
23 
26 

2 
5 
9 
6 
33 

27 
38 
21 
29 
20 

10 
3 
9 

8 
7 

10 
4 

2 

7 

4 
3 
3 

8 
7 

20 
25 
14 
25 
59 

11 

2nd  born.   - 

8 

3rd  born  . . 

10 

4th  and  5th  born,.. 

10 

Born  Gth  or  later. 

13 

62       The  Health   of  Missionary  Families  in   China 


*° 

0. 

1 

1 

ll 

1 

■ 

1 

-■■■■ 

lull 

BORN 

t3T|2  »b|5jo|4-5J6  + 

IJT    2«I!|i*o|4-5|6«- 

1  ST  Izwolssoj*  5^1  6t- 

1  iTJ2«D|jno|4-5|6» 

CAU2£ 
OF   oeATd 

DIARRHEA,  •   ETC- 

iMALL  POX 

SIX       MAJOR 
lU  FECTION3 

fREMATURt      BIRTH 
MftCT-  MAlHOTRinOII 

Figure  28.     Mortality  of  children  from  various  causes  by  order 
of  birth.     (Illustrating  part  of  Table  48.) 


Table  39  showed  a  gradual  reduction  in  deaths  among 
children  through  the  fifth  bom.  In  looking  for  the  cause  of 
this  reduction,  in  Table  48  we  find  that  the  premature  group 
is  the  only  one  shomng  a  steady  decline,  but  that  the  diarrhoea 
and  major  infections  group  show  fewer  deaths  among  the 
third  to  fifth  born  than  among  the  first  and  second  bom. 
Parents  learn  somewhat  with  experience  how  to  guard  against 
these  infections. 

What  is  the  cause  of  the  sudden  rise  in  rates  for  the  sixth 
or  later  born  children?  There  are  only  151  of  this  group.  The 
rise  is  almost  entirely  due  to  four  groups,  %"iz.,  miscellaneous 
causes,  smallpox,  diarrhoea,  and  respiratory  infections.  Small- 
pox causes  six  times  the  number  of  deaths  in  these  later  bom 
children  that  it  causes  in  the  first  to  fifth  born.  Can  it  be  that 
parents  with  six  or  more  children  find  the  task  of  providing 
protective  vaccination  for  the  last  born  children  too  burden- 
some? 

Dysentery  and  major  infections,  be  it  noted,  diminish  in 
power  over  the  last  bom.  Is  this  because  of  better  preventive 
measures  learned  through  experience,  or  because  of  acquired 
resistance? 


The  Health   of  the   Children 


63 


NUMBER    OF    CHILDREN    IN    FAMILY 

Table  49  MORTALITY  OF  CHILDREN  FROM  VARIOUS  CAUSES  BY  NUMBER  OF 

CHILDREN  IN  FAMILY 


Total 

Number  of  Deaths  Per  1,000  Living  Births  From  Specified  Causes 

NUMBER  OF 

2 

a 

S 

"S 

CHILDREN 

Number 

"o 

, 

3 

a 

IN  FAMILY 

of  Living 

1 

>. 

a 

s 

CQ 

Births 

a 

1 

o. 

1 

a 

■rt.a 
^1 

£ 

3 

a 

1 

O 

o 

Q 

Q 

Pi 

t/2 

M 

03 

PL, 

»a 

-< 

o 

1 _ 

264 
380 
6S9 
625 
490 
523 

11 

18 
27 
24 
20 
38 

4 

8 
16 
19 
16 
29 

4 
18 
36 
35 

24 

48 

4 
16 

6 
10 

6 

8 

19 
3 
7 
6 

...... 

4 

13 
2 
6 

11 

16 
22 
22 
35 
29 

24 

2 

26 
14 
14 
16 
23 

8 
1 
6 
2 
21 

5 

3... 

7 

4 

6 

5 

14 

6  or  more- 

19 

.1 


II. 


I 


m  mnr    ra 


J       4        5       £H 


D Y  5  t  N  T  £  ^V 


DIARR-HEA      CHOLe.R.A 


MAJOR.     INftCT10N5 


HLKVTKl  riON 


Figure  29.     Mortality  of  children  from  various  causes  by  number  of 
children  in  families.     (Illustrating  part  of  Table  49.) 

Table  40  showed  a  three-fold  increase  in  total  deaths  for 
the  families  with  six  or  more  children  over  the  families  with 
one  child.  In  Table  49  and  Figure  29  we  see  that  this  increase 
is  due  to  the  principal  infectious  diseases.  Deaths  from  dys- 
entery increased  3.6  times,  diarrhoea  7  times,  major  infections 
12  times,  and  smallpox  (average  of  first  five  groups)  nearly 
7  times.  On  the  other  hand,  deaths  from  respiratory  infec- 
tions, birth,  malnutrition,  etc.,  have  not  increased  with  the 
increasing  size  of  the  family. 

This  means  that  quarantine  within  the  family,  especially 
for  the  air-borne  infections,  has  been  at  fault.  Deaths  from 
dysentery  and  diarrhoea  have  been  twice  the  average  increase, 
but  deaths  from  the  group  of  diphtheria,  scarlet  fever,  mala- 
ria, tuberculosis,  meningitis  and  typhoid  have  been  four  times 
the  average.  This  is  in  spite  of  the  fact  that  deaths  from 
these  infections  among  later  born  children  are  less  than 
among  earlier  born.    Study  of  individual  reports  shows  infec- 


64       The  Health  of  Missionary  Families  in   China 

tions,  once  started,  run  through  families  as  they  would  not  in 
communities  where  isolation  and  quarantine  are  strictly 
enforced. 

CAUSES  OF  DEATH  BY  INDIVIDUAL  DISEASES 

Table  50  gives  the  number  dying  from  these  various  dis- 
eases, and  the  ages  at  death.  Figure  30  shows  the  percentage 
of  the  total  deaths,  in  which  a  cause  was  given,  due  to  the 
various  diseases  or  groups  of  diseases.  Dysentery  alone  has 
caused  nearly  a  fifth  of  the  deaths.  Dysentery  together  with 
the  acute  intestinal  infections  (diarrhoea,  enteritis,  cholera, 
etc.)  have  caused  nearly  a  third  of  the  total. 

Sixty-nine  per  cent  of  the  deaths  from  dysentery  and 
81%  of  those  from  diarrhoea  occurred  during  the  first  two 
years  of  life. 


Table  50 


CAUSES  OF  DEATHS  OF  CHILDREN  WITH  AGE  AT  TIME  OF  DEATH 


Total 
All 

Ages 

Number  of  Deaths  at  Ages  Specified 

DISEASE 

MONTHS 

YEARS 

0-1 

1-2 

3-5 

6-11 

0-1 

1 

2 

3 

4 

5 

-10 

-20 

N.S. 

77 

1 

( 

19 

26 

27 

11 

6 

3 

4 

47 

1 

3 

6 

11 

21 

17 

4 

1 

1 

2 

1 

51 

2 

2 

5 

12 

21 

14 

10 

2 



3 

1 

24 

2 



2 

7 

6 



3 

6 

19 

2 

1 

4 

3 

10 



3 



4 

2 

Meningitis                          

17 

2 

3 

5 

4 

2 

1 

2 

1 

2 

Scarlet  Fever                    . .  

16 

1 

1 

1 

4 

9 

Typhoid  Fever                   .       

12 

1 

1 

3 

1 

1 

1 

3 

2 

10 

2 

2 

1 

3 

2 



2 

10 

2 

2 

2 

1 

1 

2 

2 

20 

2 



2 

3 

7 

3 

3 



1 

4 

2 

19 

18 



1 



19 

10 

9 

1 

10 

Birth  Defect 

12 

6 



1 

3 

10 

1 

1 

14 

2 

1 

4 

4 

11 

2 

1 

5 

3 

1 

1 

5 

17 

1 



3 

4 

8 

2 



3 

3 

1 

9 

1 

1 

2 



1 

1 

2 

2 

War_.                            

11 

4 

6 

1 

44 

20 

2 

3 

8 

33 

3 

1 

--- 

2 

1 

2 

2 

Total--- 

444 

67 

11 

41 

75 

194 

87 

48 

17 

19 

41 

19 

17 

2 

*Age  not  stated. 


The  Health   of  the   Children 


65 


CAUM    Of    OtATH 


PERCENT      Of      BEATHS 


}  hhhhhhhT^riy^ 


OVitHTERY 


REiPIRATOR'T 


RIHTM     OErtCTS 
^     INJURIES 


rtlSCELLANEOUi 
INFECTIONS 


WAX    4  AlCCIOENT 


mSCEU-ANEDOl 
CONOniONk 


f^ALNOTUlTION 


iCAHLET     PEVER 


TYPHOID   FEVER 


TUBERCULOil!, 


Figure    30.     Percentage    of   deaths    of   children    from   various   causes. 
(Derived  from  Table  50.) 


In  the  table  "diarrhoea"  includes  all  cases  of  acute  intestinal  infection 
other  than  dysentery  and  typhoid  fever.     Seven  cases  were  listed  as  cholera. 

"Respiratory"  includes,  besides  pneumonia,  six  cases  of  bronchitis  and 
six  of  whooping  cough.  Of  the  children  dying  of  whooping  cough,  five  were 
aged  one  year  or  under,  one  was  five  years  old. 

"Diphtheria"  includes  three  cases  listed  as  tonsilitis. 

"Other  Infections"  include  fever  three,  appendicitis  three,  vaccination 
two,  erysipelas  two,  measles  two,  and  one  each  of  liver  abscess,  typhus  fever, 
sore  throat,  influenza,  sprue,  kalaazar,  infantile  paralysis,  and  blood  poisoning. 

"Miscellaneous"  includes  heart  trouble  three,  nephritis  two,  hardship 
two,  and  one  each  of  intersusception,  spinal  disease,  diabetes,  jaundice,  cir- 
cumcision, poisoning,  sunstroke,  sewage  gas,  myxedema,  and  seasickness. 

"Accident"  includes  three  killed  by  bandits,  two  by  drowning,  one  suffo- 
cated by  quinine  pill. 

"Premature"  births  were,  in  one  case  each,  said  to  be  due  to  eclampsia, 
dysentery,  malaria,  and  quinine. 

Three  of  the  ten  deaths  from  tuberculosis  were  due  to  tuberculous 
meningitis. 


66       The  Health   of  Missionary  Families  in   China 


Table  51 


PERCENTAGE  OF  DEATHS  OCCURRING  AT  SPECIFIED  AGES,  DUE  TO  VARIOUS 
CAUSES,  COMPARED  WITH  UNITED  STATES  AND  ENGLAND 


CAUSE  OF  DEATH 

Missionary 
Children 

United  States 

1918 

(Native  White  Parents) 

England  and  Wales 
1917 

0-1 
Year 

Under 
5  Years 

5-9 
Years 

0-1 
Year 

Under 
5  Years 

5-9 

Years 

0-1 
Year 

Under 
5  Years 

^9 
Years 

Typhoid  Fever. .  _ 

.6 

2.1 

7.5 

.03 

.16 

2.7 

.001 

.01 

.4 

Malaria 

1.3 

2.5 

5. 

.09 

.15 

2.7 

Smallpox.. 

6  3 

5.2 

5. 

.01 

.02 

.04 

Measles. . 

1.2 

.8 

1.3 

2.9 

3.4 

2.8 

8.9 

7.5 

Scarlet  Fever. . 

2.1 

22.5 

.08 

.55 

3.3 

.05 

.4 

1.8 

Diphtheria  and  Croup 

1.3 

5.6 

10.5 

.5 

3. 

13.7 

.2 

2.2 

13.8 

Dysentery. 

16. 

23. 

10. 

.4 

.6 

.5 

.01 

.01 

.03 

Tuberculosis 

1.3 

1.5 

2.5 

1.5 

2.7 

7.4 

2.9 

6.1 

22. 

Syphilis . 

1.2 

.9 

2 

2.1 

1.4 

.06 

Meningitis.  __  . 

3.1 

4. 

5. 

.8 

1.3 

2.7 

1.4 

2. 

4.4 

Bronchitis,  Pneumonia  and 
Whooping  Cough 

13.3 

14. 

7.5 

16.6 

18.8 

9.9 

23.4 

26.8 

13.2 

Cholera,  Diarrhea,  Enteritis 

13.5 

13.5 

2.5 

23.1 

22.2 

10.7 

8.9 

2. 

Premature  Birth 

11.3 

5.5 

20.4 

14.4 

19.9 

12.2 

Injury  at  Birth 

6. 

2.4 

4.1 

2.8 

1.2 

.7 

Total 

75.2 

82.4 

78. 

70.1 

70.5 

46.5 

64.6 

09.6 

65.1 

All  other  causes 

24.8 

17.8 

22. 

29.9 

29.5 

53.5 

35.4 

30.4 

34.9 

Table  51  compares  the  principal  causes  of  death  among 
missionary  children,  the  white  population  of  America,**  and 
the  general  population  of  England  and  Wales."^  The  figures 
are  the  percentage  of  the  total  deaths  for  the  ages  specified. 

It  should  be  noted  that  diagnoses  given  by  parents  are  oftentimes  inac- 
curate, as  their  idea  of  the  doctor's  diagnosis  may  be  in  error,  or  there  may 
have  been  no  doctor  in  attendance.  In  government  statistics,  on  the  other 
hand,  diagnoses  are  nearly  always  made  by  the  physician  in  attendance.  For 
this  reason,  no  emphasis  is  laid  on  any  but  the  well  marked  differences  in 
Table  51.  Again,  the  figures,  being  percentages  of  the  total  number  of  deaths 
for  the  various  ages,  would  total  100  for  each  age  group.  Other  diseases  not 
named  in  the  table  (mainly  those  classed  under  "other  fevers"  and  "miscel- 
laneous") would  show  higher  percentages  for  England  and  America  than  for 
missionaries.  In  the  table,  percentages  for  respiratory  infections,  prematur- 
ity, measles,  tuberculosis,  and  syphilis  are  lower  among  missionary  children 
than  among  children  in  England  and  America. 


The  Health   of  the   Children 


67 


Figure  31.     Percentage  of  deaths  under  one  year  of  age  from  various  causes 

among  Missionary  Children  and  children  in  the  United  States  and 

England.     (Illustrating  part  of  Table  51.) 


The  most  significant  differences  are  shown  in  the  three 
following  charts.  Figure  31  gives  the  deaths  under  one  year. 
Three  points  stand  out:  (1)  The  high  black  tower  represent- 
ing deaths  from  dysentery,  40  times  higher  than  the  corre- 
sponding column  for  England  and  Wales,  and  1,600  times  that 
for  the  United  States.  (2)  The  black  gravestone  standing 
over  smallpox — a  monument  to  lives  needlessly  sacrificed. 
(3)  A  death  rate  from  prematurity  only  one-half  the  standard 
(for  which  the  absence  of  venereal  disease  may  largely  ac- 
count), but  a  death  rate  from  obstetrical  disasters  of  twice 
the  standard — probably  the  result  of  insufficient  medical 
attention. 


68       The  Health   of  Missionary  Families   in   China 


Figure  32.     Percentage  of  deaths  under  five  years  of  age  from  various  causes 

among  Missionary  Children  and  children  in  the  United  States  and 

England.     (Illustrating  part  of  Table  51.) 


The  deaths  under  five  years  from  dysentery  (Figure  32) 
show  an  even  higher  proportion  of  the  total  (23%).  Small- 
pox shows  a  rate  260  times  that  for  the  United  States  and 
infinitely  above  England,  as  that  country  had  no  deaths  at 
these  ages  from  smallpox  in  1917. 

The  comparative  infrequency  among  missionary  children 
of  deaths  from  respiratory  infections  is  striking  for  all  three 
age  groups.  The  relative  immunity  of  adults  to  influenza 
during  the  pandemic  of  1917  is  noted  elsewhere  (p.  91). 


The  Health  of  the   Children 


69 


OEATMb      5-9     YEARb 
MlbblONARX       CMILDRtN        CH\N/\ 


N    UNITED      STATES       [wMlTEi] 
^    ENC^LAND      if     WALES 


Figure  33.     Percentage  of  deaths  five  to  nine  years  of  age  from  various  causes 

among  Missionary  Children  and  children  in  the  United  States  and 

England.     (Illustrating  part  of  Table  51.) 

As  there  are  only  40  deaths  of  children  aged  5-9  recorded, 
Figure  33  has  not  as  great  value  as  the  other  charts.  Besides 
the  persistently  prominent  position  of  dysentery  and  small- 
pox, the  figure  shows  the  comparative  deadliness  of  scarlet 
fever  at  this  age.  Typhoid  fever  is  given  as  cause  of  death 
in  7.5%  of  the  cases.  This  points  the  need  of  typhoid  inocu- 
lation for  children  of  this  age. 


Table  52 


DEATHS   OUTSIDE   CHINA 

CAUSES  OF  DEATHS  OCCURRING  OUTSIDE  OF  CHINA 


CAUSE  OF  DEATH 

Number 

Ages  at  Death 

SOCIETIES 

Infantile  Paralysis 

Dysentery 

Diarrhea. 

1 

2 
3 
1 

2 
3 
1 

2 

1 
2 
1 
1 
1 
2 
1 
2 

1 
10 

3  days 
1.2 
1 
2 

1.4 
4,  8,  21 
19 

19,21 
4  mo. 
10  mo.,  26 
6 
4 
2 
5  mo.,  8  mo. 
6  days 
14,  15 
8  mo. 
18,  19  (3) 
20,  21  (2) 
23,  25,  26 

Swed.  All.  Miss. 

Swed.  Miss.  Soc,  Danish  Lutheran. 

Y.  M.  C.  A.,  Baptist  No.,  Pres.  South. 

Pneumonia 

Whooping  Cough 

Typhoid  Fever..  . 

Yale. 

Presbyterian,  South  (2) 

Baptist,  South.  (3) 

American  Lutheran. 

Tuberculosis 

Other  English. 

Other  English. 

Meningitis  .. 

Swed.  Miss.,  Bapt.,  South. 

Scarlet  Fever.. 

European  C.  I.  M. 

Appendicitis 

Septic  Sore  Throat 

Other  English. 
American  Board. 
Y.  M.  C.  A.  (2) 

Premature 

C.  I.  M. 

Other  American,  Pres.  No. 

"Seasickness". 

Other  European. 

Killed  in  War 

London  Miss.  (2);  Other  English  (2). 

Eng.  Bapt.,  C.  I.  M.  (5) 

Total 

37 

70       The  Health  of  Missionary  Families  in   China 

Thirty-seven  deaths  are  recorded  as  occurring  outside  of 
China,  This  is  8.2%  of  the  total  number  of  deaths.  Of  these, 
five  children  died  on  board  ship  going  to  or  from  China.  Two 
others  died  while  in  Korea  and  Japan.  So  that  only  Q.Q%  of 
the  deaths  occurred  while  children  were  in  the  homeland.  If 
the  deaths  from  war  are  excluded,  this  leaves  only  19,  or  4.4% 
of  the  total  deaths.  About  33%  of  the  children's  life  was  spent 
at  home.  As  only  6.6%  of  the  deaths  occurred  there,  there  are 
about  five  chances  of  the  child  dying  in  China  to  one  of  his 
dying  in  the  homeland.  It  must  be  remembered,  however, 
that  most  of  the  "homeland"  years  were  those  of  later  child- 
hood, when  mortality  is  lower  than  in  early  life. 

Sometimes  missionaries  are  accused  of  a  lack  of  patriot- 
ism. Eleven  children  of  English  missionaries  died  in  the  war, 
one  of  disease,  and  ten  killed  in  battle.  In  the  four  societies 
represented,  one-third  of  the  children  who  have  died,  aged 
five  years  and  over,  have  died  while  in  the  service  of  their 
country. 

MORBIDITY   AMONG   CHILDREN 

So  far  this  study  has  been  concerned  with  the  deaths  of 
children.  Many  sicknesses,  however,  do  not  result  in  death, 
and  yet  prevent  robust  health. 

The  statistics  concerning  morbidity  are  not  so  reliable  as  those  con- 
cerning mortality.  Sicknesses  not  resulting  in  death  are  more  likely  to  be 
forgotten.  Furthermore,  for  malaria,  dysentery,  bronchitis,  worms,  tonsilitis, 
the  report  was  often  "many  times,"  "occasionally,"  "not  often,"  etc.,  in  which 
cases  the  illness  in  question  was  recorded  but  once.  Though  the  total  ill- 
nesses are  certainly  well  above  the  5,744  here  recorded,  the  figures  are  of 
value  for  comparative  purposes  within  the  group.  In  order  to  make  the 
comparison  as  accurate  as  possible,  the  sicknesses  reported  are  reduced  to  the 
number  per  1,000  years  of  residence.  The  tables  concerning  morbidity  and 
general  health  are  based  on  the  histories  of  3,036  children  only.  This  gives 
an  average  of  1.9  illnesses  per  child. 


The  Health  of  the  Children 


71 


Table  53    ABSOLUTE  NUMBER  OF  CASES  OF  PRINCIPAL  INFECTIONS  AND  NUMBER  PER  1000 
YEARS  OF  RESIDENCE  BY  PROVINCES. 


SICKNF.SS 

.2 
1 

to 

1 

1 

03 

d 

CO 

1 

3 

a 

-a 
a 
< 

a 
a 

'■% 

0 

a 
a 
W 

M 

1 

& 

0 

-a 

1 

tS 

a 

3 

w 

a 

3 

a 
1 

a 

Total  Years  of-  Residence 

3S1 

1527 

1448 

569 

593 

470 

2359 

651 

1083 

1263 

476 

1069 

850 

1672 

886 

1321 

Number  of  Sicknesses  per  1000  Years  of 

Residence 

Total  per  1000  yrs.. 

300 

245 

216 

348 

200 

257 

301 

203 

263 

254 

247 

214 

306 

203 

184 

226 

Dysentery  __ 

60 
21 
18 
12 

.3 

3 

24 
13 
10 
10 
5 
8 

41 

9 
15 

7 

9 

5 
0.7 
13 

5 
12 
10 
30 

7 
21 
21 

9 

69 
17 
12 

"9' 
19 
4 
21 
4 
10 
26 
45 
10 
35 
52 
14 

32 
23 
11 
11 
2 
12 

15 
6 
6 
6 
2 

17 

42 
9 
9 

12 
8 
2 

18 
7 

12 
6 

""3' 
6 

"is' 

6 

47 
16 
24 
26 

1 

21 

7 
12 

6 

6 

4 

.9 

7 

3 
39 
11 
32 
11 
39 
56 

9 

58 
5 
4 
7 

10 

2 

..... 

3 
14 

5 
51 
11 
30 
32 
16 

50 

6 

8 

4 

2 

2 

2 

8 

2 

38 

6 

39 

21 

29 

21 

8 

23 
12 
12 
9 

..... 

4 
4 
10 
23 
8 
33 
13 
14 
24 
11 

43 
16 
17 
11 

8 

"'8 
6 
4 

13 
8 

63 
6 

47 

43 
2 

23 

8 
10 

9 
1.8 

5 

1 
11 

2 
19 

2 
47 

7 
16 
26 
12 

16 
10 
6 
7 
6 
7 
.... 

33' 
4 

31 
4 

13 

30 

14 

28 

g 

Bronchitis 

g 

Pneumonia... 

5 

Diphtheria 

5 

Smallpox. 

1 

Meningitis 

7 

30 
3 
12 
21 
42 
12 
27 
21 
12 

24 

6 

5 

7 

32 

18 

26 

31 

22 

17 
11 
13 

"28" 

7 

20 

13 

8 

34 

"I' 
61 
25 
21 
42 
4 

13 
7 
35 
6 
47 
16 
36 
35 
15 

2 

Typhoid  Fever 

Malaria 

2 
35 

Influenza 

5 

Measles 

19 

Mumps.     . 

13 

Chicken  Pox 

Whooping  Cough 

Tonsilitis 

38 
37 
15 

Nui 

tfBER  OF  Si 

3KNES 

JES 

Total  Sicknesses 

99 

373 

313 

198 

119 

121 

712 

136 

284 

320 

118 

229 

260 

340 

163 

299 

Dysentery 

20 

7 
6 
4 

1 
1 

37 
21 
15 
15 
7 
13 

59 
14 
21 
11 
14 
7 
1 
20 
7 
17 
15 
44 
10 
30 
30 
13 

39 
9 
7 
4 
5 

11 
2 

12 
2 
6 

15 

26 
6 

20 

30 
8 

19 
14 
6 
7 
1 
2 

""9' 
7 
8 

"17" 
4 
12 
8 
5 

7 
3 
3 
5 

1 

8 

1 

16 

"2" 
31 
12 
10 
20 
2 

101 
22 
22 
29 
19 
4 
4 
31 
16 
81 
14 

111 
50 
86 
83 
36 

12 
5 

88 
4 

"2 
4 

12' 

4 
31 
11 
16 
17 

7 

23 

8 

13 

7 

6 

4 

1 

8 

3 

42 

11 

35 

11 

42 

60 

10 

66 
7 
6 
8 

13 
3 

""16' 
4 

18 
7 
65 
14 
38 
41 
20 

24 
3 
4 
2 
1 
1 
1 
4 
1 
17 
3 

19 
10 
14 
10 
4 

25 
14 
13 
10 

..... 

4 
4 
11 
26 
9 
36 
14 
16 
27 
12 

37 
14 
15 

9 

3 

'3" 

5 

4 
11 

7 
54 

6 
38 
37 
16 

38 
13 
17 
16 
2 
8 
2 

19 
4 
32 
4 
80 
13 
28 
44 
20 

14 
9 
5 
6 
5 
6 
.... 

'29" 
4 
28 
4 
12 
27 
13 

37 

Diarrhea,  etc...     .  _  . 

13 

Bronchitis..  

11 

Pneumonia 

g 

Diphtheria .  .  .. 

g 

Smallpox 

2 

Meningitis 

1 

Scarlet  Fever 

Typhoid  Fever 

10 
1 
4 
7 

14 
4 
9 
7 
4 

37 
9 
8 
10 
48 
28 
39 
50 
35 

3 
3 

46 

Influenza .. 

7 

Measles  .. 

26 

18 

Chicken  Pox 

51 

Whooping  Cough 

Tonsihtis.. 

49 
20 

Table  53  shows  both  the  relative  and  the  absolute  number 
of  the  principal  sicknesses  for  each  of  the  provinces.  It  will 
be  observed  that  the  provinces  with  the  largest  number  of 
illnesses  are  not,  necessarily,  the  ones  with  the  highest  mor- 
tality, i.e.,  those  with  the  highest  absolute  number  of  cases, 
may  not  have  the  highest  percentage  of  cases.  For  instance, 
Kiangsu  reports  101  cases  of  dysentery — half  again  the  num- 
ber of  the  next  highest  province.  But  it  stands  only  sixth  in 
the  number  of  cases  in  relation  to  the  number  of  years  spent 
in  China.     The  density  of  the  missionary  population  in  the 


72        The  Health   of  Misslonnry   Fdnillies   in    China 

Ymigise  valley  gives  that  section  the  reputation  of  an  unduly 
hii!:h  dysentery  rate,  which  reputation,  so  tar  as  the  children 
are  concerned,  is  undeserved. 


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Figure  o4.  Number  of  cases  of  dysentery  per  1,000  years  of  residence  among 
children  by  provinces  (from  Table  oo).  Number  of  dots  represents  num- 
ber of  cases  per  1,000  years"  residence  per  unit  square  of  surface,  e.g.,  100 
square  miles.  The  figures  indicate  simply  the  number  of  cases  per  1,000 
years  of  residence.  Absence  of  boundary  lines  between  provinces  indi- 
cates that  data  from  these  provinces  lu-e  combined. 


The  distribution  of  dysentery  shown  in  Figure  34  is  of 
interest.    Provinces  reporting  most  dysentery  per  1,000  yeai^ 


The  Health  of  the  Children 


73 


are:  Shansi,  69;  Manchuria,  60;  Honan,  58.  A  wide  gap  sep- 
arates these  from  the  provinces  reporting  least,  viz.:  Che- 
kiang,  11;  Kansu,  15;  Fukien,  16. 

Shansi  and  Kansu  have  the  distinction  of  reporting  the 
most  cases  of  smallpox.  Kansu,  Manchuria,  Shantung  and 
Shansi  have  far  more  scarlet  fever  than  the  other  provinces. 
Chekiang,  Kiangsi,  Kiangsu  and  Kwangtung  report  the  most 
malaria.  Of  the  total  sicknesses  tabulated,  Shansi  reports  the 
most,  P^ukien  the  fewest. 

Round  worms  are  not  classified  in  the  table.  Various 
provinces  reported  infection  per  1,000  years  as  follows: 
Fukien,  41.7;  Hunan  and  Kweichow,  40.4;  Kwangtung,  33.3; 
Hupeh,  29;  Chekiang,  26;  Kiangsu,  25.8;  Honan,  23;  Shan- 
tung, 21;  Szechuan,  20;  Cliihli,  13.1.  Definite  sickness  from 
round  worms  was  named  but  once  (jaundice,  with  death); 
13.4%  of  the  children  were  reported  as  having  had  round 
worms. 

The  chief  diseases  for  the  sections  are  shown  in  Figure  35. 

Besides  the  sicknesses  listed  in  the  table,  the  following  are  reported, 
the  number  beinjj  too  small  to  make  division  into  provinces  of  value:  Round 
worms,  402;  hook  worm,  12;  pin  worm,  31;  operation,  tonsil  or  adenoid,  157; 
mastoid,  4;  hernia,  9;  difficult  feeding,  90;  malnutrition,  29;  heart  disease, 
24;  tuberculosis,  23;  appendicitis,  not  operated  11,  operated  23;  rheumatism, 
19;  rickets,  13;  trachoma,  13;  kidney  disease,  8;  relapsing  fever,  5;  cholera, 
5;  tapeworm,  4;  St.  Vitus  dance,  4;  cyclic  vomiting,  3;  erysipelas,  3;  men- 
tally   defective,    3;    kalaazar,    1;    infantile   paralysis,    2;    miscellaneous,    14; 


total,  812. 
Table  54 


NUMBER  OF  PRINCIPAL  INFECTIONS  BY  SECTIONS  OF  CHINA,  AND  OCCURRING 
OUTSIDE  OF  CHINA. 


North 

Central 

South             All 
China 

Outside 
China 

SICKNESS 

Number  ok  Years  of  Residence 

Province  or 
Years  of  Residence 
Not  Stated 

4940 

9436 

2227 

16,573 

8748 

Nci 

IBER  OF  Cases  of  Specified  Sick 

VE88 

TOTAL 

1227 

2425 

462 

4,114 

708 

110 

Dysentery 

181 
68 
59 
46 
29 
42 
4 

104 
26 
43 
49 

180 
64 

120 

145 
66 

326 

85 

98 

85 

44 

28 

17 

85 

43 

242 

59 

462 

129 

278 

319 

125 

51 

22 

16 

12 

11 

8 

1 

4 

3 

75 

11 

54 

22 

63 

76 

33 

558 

175 

173 

143 

84 

78 

22 

193 

72 

362 

119 

696 

215 

461 

540 

225 

14 
12 
6 
17 
12 
...... 

38 

10 

9 

3 

232 

68 

91 

171 

19 

23 

e, 

Bronchitis 

7 

Pneumonia ... 

f, 

Diphtheria 

2 

Smallpox 

5 

Meningitis 

0 

Scarlet  Fever 

7 

Typhoid  Fever 

5 

Malaria 

11 

Influenza . 

0 

Meaales 

3 

Mumps .. 

11 

Chicken  Pox  ... 

8 

Whooping  Cough 

11 

Tonsifitis 

5 

74       The  Health  of  Missionary  Families  in   China 

Table  54  gives  the  total  number  of  sicknesses  by  sections, 
together  with  the  sicknesses  contracted  outside  of  China. 

Diseases  contracted  outside  of  China  not  named  in  Table  54  are  the 
following:  Infantile  paralysis,  6;  malnutrition,  2;  appendicitis,  6;  rheuma- 
tism, 3;  heart  trouble,  1;  kidney,  1;  tuberculosis,  1;  round  worms,  1;  pin 
worms,  2;  erysipelas,  1;  total,  24. 

The  only  disease  which  is  not  the  more  common  in  China 
is  infantile  paralysis ;  two  cases  were  reported  from  China,  as 
against  six  reported  from  outside  China. 


Table  55 


NUMBER  OF  PRINCIPAL  INFECTIONS  PER  1000  YEARS  OF  RESIDENCE,  BY 
SECTIONS  OF  CHINA  AND  OCCURRING  OUTSIDE  OF  CHINA. 


Number  or  Cases  per  1000  Years  op  Residence 

SICKNESS 

OccDRRiNO  IN  China 

Occurring  Outside 
OF  China 

North 
China 

Central 
China 

South 
China 

All 
China 

TOTAL 

248 

257 

209 

249 

81 

Dysentery    ..            .-                 

37 
13 
12 
11 

6 

9 

.8 
21 

5 

9 

10 
36 
13 
24 
29 
13 

34 

9 

13 

9 

5 

3 

2 

9 

5 

25 

16 

49 

14 

28 

33 

13 

23 

9 

7 

5 

5 

4 
.4 

2 

1 
33 

5 
24 

9 
28 
34 
25 

34 
11 

9 

8 

5 

5 

1.4 
12 

4 
22 

7 
42 
13 
28 
33 
14 

1.6 

1.4 

.6 

2. 

1.4 

Smallpox 

Meningitis       _              -_--.  

.5 

4.3 

1.1 

Malaria..                _........ 

1.0 

.4 

26.6 

Mumps 

7.0 

10.0 

19.9 

Tonsilitis  .                    ......... 

2. 

Figure  35.   Number  of  infections  of  various  diseases  per  1,000  years'  residence' 
by  sections  of  China.     (Illustrating  part  of  Table  55.) 


The  Health  of  the  Children 


7S 


Table  55  gives  the  sicknesses  of  Table  54  expressed  in 
number  of  sicknesses  per  1,000  years  of  residence.  Central 
China  has  a  slightly  higher  morbidity  than  North  China,  due 
to  excess  of  malaria  and  measles.  South  China  exceeds  other 
sections  only  in  the  amount  of  malaria,  tonsilitis  and  whoop- 
ing cough.  Its  total  rate  would  be  higher  if  cases  of  round 
worms  and  all  cases  of  malaria  were  included.  Figure  35 
illustrates  a  portion  of  Table  55. 


Figure  36.     Number  of  cases  per  1,000  years'  residence  of  various  dis- 
eases contracted  in  China  and  outside  of  China.     (Illustrating 
part  of  Table  55.) 


Figure  36  shows  the  comparative  number  of  sicknesses 
contracted  in  China  and  outside  of  China.  The  highly  con- 
tagious children's  diseases,  scarlet  fever,  measles,  mumps, 
chicken  pox,  and  whooping  cough,  are  contracted  while  the 
children  are  home  more  frequently  than  the  other  diseases. 
The  comparatively  low  rate  of  sickness  of  children  while  at 
home  is  to  be  accounted  for  in  part  by  the  fact  that  children 
are  home  for  school  during  the  later  years  when  they  are  less 
susceptible  to  the  serious  infections. 

PERCENTAGE    OF   MORTALITY 

We  have  seen  that  more  children  die  in  the  north  than  in 
the  south.  This  is  partly  because  more  serious  diseases  are 
prevalent  in  the  north.  But  it  is  also  (Table  56  and  Figure 
37)  due  to  the  fact  that,  for  practically  all  the  diseases,  the 


76       The  Health  of  Missionary  Families  in   China 

north  shows  a  higher  percentage  of  mortality  than  the  south. 
This  may  be  because  of  greater  virulence  of  the  disease,  or 
because  of  less  provision  for  medical  care.  It  is  not  because 
children  in  the  north  are  less  robust.    (See  Table  61.) 


Table  56 


PERCENTAGE  OF  MORTALITY  FOR  VARIOUS  DISEASES,  BY  SECTIONS 


DISEASE 

North 

Central 

South 

All  China 

12.1 

20.8 

3.3 

28.2 

34.3 

28.5 

75.0 

12.5 

17.2 

46.5 

0.5 

1.4 

10.4 

26.7 

2.0 

17.7 

25.0 

35.7 

58.8 

2.3 

9.3 

0.8 

7.8 
4.5 

"io"o" 

10.0 

21.7 

2.2 

20.2 

25.0 

28.1 

63.6 

7.7 

12.5 

2.2 

0.1 

0.37 

Figure  37.     Percentage  of  mortality  for  various  diseases  by  sec- 
tions of  China.     (Illustrating  part  of  Table  56.) 


MAJOR   AND   MINOR   INFECTIONS 

Because  of  the  evident  importance  of  the  infections,  vari- 
ous infectious  diseases  are  divided,  in  Tables  57-58,  into  two 
classes,  and  comparison  made  among  provinces  and  societies 
as  to  the  number  of  cases  per  1,000  years  of  life. 

The  major  infections  include  dysentery,  diarrhoea,  cholera,  etc.,  pneu- 
monia, tuberculosis,  meningitis,  typhoid  fever,  scarlet  fever,  smallpox, 
typhus,  cholera,  malaria,  and  infantile  paralysis.  Minor  infections  include 
measles,  mumps,  chicken  pox,  bronchitis,  intestinal  worms,  etc.  Infections 
contracted  both  in  China  and  at  home  are  counted. 


The  Health   of  the   Children 


77 


GEOGRAPHICAL   LOCATION 

Table  57                          NUMBER  OF  INFECTIONS  OF  CHILDREN  BY  PROVINCES 

PROVINCE 

No.  OF  Infections 

Number  of  Infections  per 
1000  Years  of  Life 

Major 

Minor 

Major 

Minor 

53 
191 
147 

99 
104 

55 

56 
307 
258 
137 
75 
94 

83. 

61. 

78. 
128. 
130. 

85. 

94. 

Shantung,.  .  _.  

134. 

Chihli. 

124. 

Shansi-..                .  . 

161. 

Shensi 

96. 

Kansu 

145. 

North! 

649 

927 

83. 

128. 

Kiangsu  ..... 

376 
54 

144 

129 
50 

121 
79 
23 

172 

622 
114 
250 
299 

S3 
172 
188 

27 
288 

116. 

62. 
106. 

67. 

81. 

75. 

83. 
125. 

61. 

192. 

131. 

Honan _  .  .. 

184. 

Chekiang ... 

156. 

Kiangsi 

134. 

Hupeh 

107. 

Hunan .  ... 

200. 

Kweichow 

156. 

Szechuan  .   

102. 

Central 

1148 

2043 

84. 

149, 

Fukien.   

91 
171 

8 

252 
342 

8 

61. 
77. 
85. 

170. 

Kwangtung 

154. 
85. 

South 

270 

602 

71. 

159. 

All  China.. 

2067 

3572 

81, 

144. 

The  major  infections  are  equally  frequent  in  North  and 
Central  China,  but  less  frequent  in  South  China.  The  minor 
infections,  on  the  other  hand,  increase  from  north  to  south. 
(This  tabulation  includes  intestinal  parasites.) 


Table  58 


MISSIONARY   SOCIETIES 

NUMBER  OF  INFECTIONS  OF  CHILDREN  BY  SOCIETIES 


SOCIETY 

Number  of  Infections   per   1000   Years 

Major 

Minor 

English  Baptist 

123. 
113. 
103. 

93. 

89. 

84. 

84. 

81. 

80. 

79. 

75. 

70. 

70. 

67. 

62. 

58. 

56. 

163. 

American  Church  Mission  .  .  

261. 

Scandinavian  Societies. .  

102. 

Y.M.C.A....                                             

294. 

American  Baptist,  South                              

115. 

American  Lutheran  Societies                 .       

172. 

American  Board.,,                                       

135. 

Other  English  Societies...              .       .  .  

117. 

Cand.  Methodist                                                                .              .  . 

145. 

Other  Am.  Soc- 

159. 

Am.  Methcdist,  No 

163. 

German  and  Swiss  .                                                       

56. 

Am.  Bapt.,  North 

117. 

China  Inland 

122. 

Church  Mis.  Soc. _. 

83. 

London  Miss _          

121. 

Am.  Pres.,  No.    

147. 

All  Societies .. 

76. 

132. 

78       The  Health  of  Missionary  Families  in   China 

In  Table  58  the  infections  are  rearranged  by  societies 
(the  division  into  societies  is  somewhat  different  from  that 
used  in  previous  tables.) 

The  societies  with  the  smallest  number  of  major  infec- 
tions are  not  necessarily  those  with  the  lowest  mortality.  This 
may  be  due  partly  to  comparative  lack  of  medical  care,  inland 
location  of  stations,  etc.  It  may  be,  also,  that  the  members  of 
some  societies  have  been  less  careful  than  others  in  naming  aU 
the  sicknesses. 

Note  that  minor  infections  do  not  decrease  at  the  same 
rate  as  major  infections.  Here  again  the  neglect  of  mention- 
ing the  trivial  diseases  may  be  a  large  factor. 

AGE   AT   TIME   OF   SICKNESS 

It  is  important  to  know  at  what  ages  children  are  most 
liable  to  contract  the  various  diseases.  Age  at  time  of  sick- 
ness was  not  recorded  for  many  of  the  sicknesses.  Data  con- 
cerning nine  of  the  more  important  diseases,  totaling  1,291 
sicknesses,  are  recorded  in  Table  59. 

Children  aged  two  {i.e.,  during  the  third  year  of  life) 
show  the  largest  number  of  infections.  As  has  been  remarked 
previously,  this  is  the  year  of  greatest  susceptibility  to  un- 
healthy conditions.  During  this  third  year,  dysentery  and 
malaria  are  most  common.  Diarrhoea  and  smallpox  are  most 
prevalent  in  the  first  year — pneumonia  in  the  second,  scarlet 
fever  in  the  sixth. 


Table  59 


AGE  OF  CHILDREN    AT  TIME  OF  SICKNESS. 


Number  of  Infections  Occurring  at  Ages  Specified. 

SICKNESS 

0-1 

1 

2 

3 

4 

6 

6-10 

11-15 

16  and 
over 

Total 

Dysentery 

Diarrhea 

63 
45 
23 

6 
17 

5 

4 
12 

2 

103 
43 
37 
10 
10 
5 
9 
13 
2 

112 
21 
24 

9 
15 
10 

5 
36 

1 

54 
9 

10 
6 
5 

15 
4 

32 

43 
6 
6 

14 
9 

17 
4 

20 
2 

31 
4 
4 

12 
3 

19 
9 

27 
1 

41 
2 
10 
21 
U 
46 
16 
51 
3 

11 

1 

1 

7 

1 

15 

17 

12 

2 

459 
132 

Pneumonia 

Diphtheria 

116 

86 

72 

Scarlet  Fever 

Typhoid  Fever 

Malaria    . .  _ 

134 

72 
207 

Tuberculosis 

13 

Total 

177 

232 

233 

135 

121 

110 

201 

65 

17 

1291 

The  Health  of  the  Children 


79 


MORTALITY   RATE   IN   RELATION   TO   AGE 

Table  60  shows  the  percentage  of  the  diseases  which  re- 
sulted fatally  at  various  ages.  In  general,  the  younger  the 
child,  the  greater  the  danger  of  death.  During  the  first  year, 
for  instance,  60%  of  those  contracting  smallpox,  47%  con- 
tracting infectious  diarrhoea  and  41%  contracting  dysentery 
died.  These  figures  are  unnaturally  high  for  the  reason  that 
practically  all  the  ages  at  death  are  known,  whereas  many  of 
the  ages  for  non-fatal  sicknesses  are  not  known. 


Table  60 


PERCENTAGE  OF  SICKNESSES  RESULTING  IN  DEATH  AT  VARIOUS  AGES. 


Age  at  Time  of  Sickness 

SICKNESS 

0-1 

1 

2 

3 

4 

5 
and 
Over 

Per  Cent 
41 
47 
39 
33 
60 

""25"' 

16 

100 

Per  Cent 
26 
40 
29 
70 

"26'" 

33 

8 

100 

Per  Cent 

9 

20 

33 

66 

20 

10 

20 

9 

100 

Per  Cent 
11 
11 
10 

...... 

25 
6 

Per  Cent 

7 

"~2\" 
44 
24 
25 

Per  Cent 
5 

Diarrhea,  etc 

44 
13 

Diphtheria 

14 

Smallpox 

16 
11 

Typhoid  Fever  .          .... 

11 

Malaria 

2 

62 

GENERAL   HEALTH   OF   CHILDREN 

GEOGRAPHICAL   LOCATION 

Under  certain  conditions  of  climate,  malnutrition,  etc., 
children  may  not  have  had  any  definite  illnesses  and  yet  be  in 
poor  health.  To  cover  this  point,  parents  were  asked  to 
specify  if  the  past  general  health  of  children  has  been  robust, 
good,  fair,  or  poor.  Since  these  terms  are  open  to  individual 
interpretation,  the  tabulation  of  answers  received  on  this 
point  is  of  value  in  only  the  broadest  way. 


80       The  Health   of  Missionary  Families  in   China 


Table  61 


PAST  GENERAL  HEALTH  OF  CHILDREN— BY  PROVINCES 


Total  No. 
of  Children 

Percentage  Reporting  Health  op  Children  as 

PROVINCE 

Poor 

Fair 

Good 

Robust 

71 
232 
224 

83 
131 

67 

3 
3 
1 

4 
5 
3 

13 
17 
9 
6 
14 
3 

54 
45 
47 
52 
53 
40 

30 

35 

Chihli... 

43 

38 

28 

54 

North  China 

808 

3 

10 

47 

38 

368 
78 
186 
170 
167 
56 
156 
22 
273 

3 
1 
4 

---- 

1 
4 
9 
2 

11 
10 
9 
9 
9 
18 
17 
19 
11 

44 
36 
42 
47 
44 
52 
47 
50 
47 

41 

53 

44 

44 

Hupeh          _                            .  .  .  . 

45 

30 

Hunan                                              .  . 

32 

Kweichow 

27 

43 

1476 

3 

12 

44 

40 

Fiikipn 

167 

255 

15 

-___ 

9 
11 

51 
53 
73 

40 

33 

Yunnan 

27 

South  China 

437 

1 

7 

59 

33 

Total  All  China 

2721 

2 

10 

50 

37 

In  Table  61  is  given  the  tabulation  by  provinces.  South 
China  shows  the  smaller  proportion  of  children  whom  the 
parents  specify  as  robust,  33%,  as  against  38%  and  40%  for 
North  and  Central  China.     (See  Figure  41.) 

Though  death  is  less  common  in  the  south,  robust  health 
is  also  less  frequent.  The  explanation  for  this  apparent  con- 
tradiction lies  in  the  fact  that  diseases  of  the  south  are  those 
(such  as  malaria  and  intestinal  parasites)  which  cause  inva- 
lidism rather  than  death.  Also,  the  climate  is  more  debili- 
tating. 


MISSIONARY   SOCIETIES 

Table  62  is  arranged  by  societies  with  those  reporting 
the  highest  percentage  of  robust  children  at  the  top.  There 
is  considerable  variation  (41%)  betw^een  the  highest  and  low- 
est. Only  14%  of  all  children  are  considered  by  their  parents 
to  be  in  less  than  good  health. 


The  Health   of  the   Children 


81 


Table  62 


PAST  GENERAL  HEALTH  OF  CHILDREN  BY  SOCIETIES 


No.  of 
Children 
Reported 

Percentage  Reporting  Health 

AS 

Poor 

Fair 

Good 

Robust 

67 
114 
119 
109 
158 

81 
519 
281 

92 
253 

73 
204 
381 

99 

65 

12 
10 

7 

10 
11 

7 

9 
12 
14 
11 

8 
12 
11 
16 
23 

36 
42 
47 
43 
44 
43 
47 
45 
46 
48 
53 
49 
51 
51 
61 

52 

48 

45 

Y.  M.C.  A 

Am.  Meth.  No 

Ch.  Mis.  Soc. 

Other  Am.  Soc 

Am.  Vrea.  No 

2 
2 
5 
1 
2 
2 
3 
3 
6 
4 
5 
5 

45 

44 
44 
43 
40 
38 

Other  Eng.  Soc 

37 

London  Mis.  Soc 

Scandinavian  Soc. 

36 
33 

33 

Am.  Baptist  So _ 

27 

11 

Total 

2615 

3 

11 

47 

39 

MISCARRIAGES   AND   STILLBIRTHS 

An  important  phase  of  the  problem,  but  one  concerning 
"which  little  is  said,  is  the  number  and  cause  of  pregnancies 
which  terminate  disastrously.  Such  miscarriages,  and  still- 
births, are  a  heavy  drain  on  the  health  and  spirit  of  the 
mothers. 

"Were  it  not  for  difficult  living  conditions,  missionaries 
should  have  a  very  low  miscarriage  rate  because  of  their  free- 
dom from  syphilis. 

In  the  Babies'  Hospital,  New  York  City,  among  193  syphilitic  mothers 
22.4%  of  the  427  pregnancies  resulted  in  stillbirth  or  miscarriage.  Among 
another  150  syphilitic  women,  17.2%  of  1,001  pregnancies  resulted  in  miscar- 
riage or  stillbirth,  while  in  another  150,  with  826  pregnancies,  who  were 
known  to  be  free  from  syphilis,  the  percentage  was  only  9.4.22 

Another  authority23  states  that  30%  of  pregnancies  in  which  a  parent 
is  syphilitic  result  in  the  death  of  the  foetus,  which  is  three  times  the  rate 
observed  in  non-syphilitic  families.  He  states  also  that  3.5%  of  infant  deaths 
are  due  to  this  disease. 

The  pregnancies  among  missionary  women  which  do  not 
result  in  a  living  child  form  15.2%  of  the  total.  This  is  sev- 
eral per  cent  higher  than  we  might  expect.  The  excess  is 
accounted  for  by  the  unusual  amount  of  travel  and  work  to 
which  missionary  wives  are  subjected. 


82       The  Health  of  Missionary  Families  in   China 

GEOGRAPHICAL    LOCATION 
Table  63    NUMBER  AND  PERCENTAGE  OF  STILLBIRTHS  AND  MISCARRIAGES  BY  PROVINCES 


PROVINCE 

Number 
Living 
Births 

Stillbirths 

MiSCARRIAGEE 

Total 
Per  Cent 

Number 

Per  Cent 

Number 

Per  Cent 

85 
289 
270 
154 
84 
76 

1 
4 
5 
4 
2 
2 

1.17 
1.38 
1.85 
2.59 
2.38 
2.63 

9 
26 
37 
25 

5 
15 

10.6 
9.9 

13.7 

17.6 
5.2 

19.9 

11.8 

Shantung 

11.3 

Chihii.... 

15.5 

20.2 

Shensi 

7.6 

22.5 

North  China..    .     . 

958 

18 

1.87 

118 

12.7 

14.6 

94 
299 
448 
176 
216 
196 

70 
311 

...... 

4 
4 
2 

6 
7 

7 

'i'74' 
.87 

2.27 
.92 

3.06 

1.0 

2.25 

U 
24 
46 
20 
32 
25 
15 
42 

11.6 

11.3 

10.5 

10. 

11.4 

13.3 

23.7 

13.5 

11.6 

Honan . 

13. 

11.4 

Chekiang... 

12.7 

Hunan .          ... 

12.3 

Hupeh ._ 

16.4 

Kiangsi 

24.7 

15.7 

Central  China 

1740 

34 

1.95 

215 

12.8 

14.7 

Fukien 

182 
324 

"-"4" 

'\.'2i 

25 
57 

14.1 
19.3 

14.1 

Kwangtung- Yunnan _  .. 

20  5 

South  China 

506 

4 

.79 

83 

17.6 

18.4 

All  China 

3204 

59* 

1.84 

416 

13.4 

15.2 

*In  three  cases  province  not  specified. 


Table  63  gives  the  number  of  miscarriages  and  stillbirths 
in  relation  to  the  number  of  living  births. 

Stillbirths  formed  1.84%  and  miscarriages  13.4%  of  the 
births.  (Data  concerning  miscarriages  was  taken  from  1,165 
histories,  which  reported  3,044  living  births.) 

South  China  has  fewer  stillbirths  and  more  miscarriages 
than  the  other  sections.  The  total  percentage  for  South  China 
is  slightly  above  North  and  Central  China  (18.4%,  against 
14.6%  and  14.7%). 

As  stated  before,  15  deaths  of  which  the  parent  wrote 
merely  ''died  at  birth"  are  classed  as  stillbirths.  If  these 
were  living  at  the  moment  of  birth,  the  rate  would  be  1.38% 
in  place  of  1.84%.  In  the  general  population  of  the  United 
States  stillbirths  average  about  4%  of  living  births. 

Four  families  reported  2  stillbirths,  2  reported  3,  the 
rest  but  1. 


The  Health  of  the  Children 


83 


Table  64 


NUMBER  OF  MISCARRIAGES— BY  PROVINCES 


PROVINCE 

Number  of  Families  Reporting  Specified  Number 
of  Miscarriages 

Total 
Families 

Total 
Mis- 
carriages 

Number 

Mis- 
carriages 

0 

1 

2 

3 

4 

Marriage 

Manchuria 

Shantung 

Chihli _.. 

19 
78 
84 
18 
41 
15 

5 
11 

17 
3 
9 

8 

...... 

5 
1 

2 
2 

2 
...... 

1 

1 
...... 

25 
95 

109 
22 
56 
26 

9 
27 
37 

5 
25 
15 

.36 
.28 
.34 

Shensi 

.23 

Shansi.   _ 

.44 

Kansu.  _ 

.59 

North 

255 

53 

13 

10 

2 

333 

118 

.35 

Anhwpi 

23 
57 
126 
49 

64 
61 
21 
82 

4 
14 

18 
10 

10 
7 
5 

22 

2 
2 
11 
5 

4 
6 
2 
7 

1 

2 
2 

2 
...... 

2 

2 
1 

30 
75 
157 
64 

82 
75 
30 
113 

11 
24 

46 
20 

32 
25 
15 
42 

.37 

Honan 

.30 

.29 

Chekiang 

Hunan  and 
Kweichow 

.32 

.39 
.32 

Kiangsi 

.50 

Szechuan 

.37 

447 

89 

38 

11 

3 

626 

215 

.34 

Fukien. 

61 
86 
71 

7 
28 

2 
3 

2 
5 

2 
2 

74 
124 

8 

25 

57 

1 

.34 

Kwangtung 

Yunnan .  . 

.46 
.12 

South     .. 

163 

37 

6 

7 

4 

206 

83 

.40 

Total- 

892 

179 

57 

28 

9 

1165 

416 

.36 

Table  64  shows  the  number  of  wives  having  certain  num- 
bers of  miscarriages,  with  the  average  number  of  miscarriages 
per  family,  by  provinces.  By  this  method  of  comparison,  also, 
South  China  has  a  higher  rate  than  other  sections  (40,  as 
against  35  for  North  and  34  for  Central  China). 

23.5%  of  the  wives  reported  having  had  one  or  more  mis- 
carriages. Among  1,618  working  women  questioned  in  Man- 
chester, New  Hampshire,'*  the  percentage  was  only  12. 


Table  65 


SUMMARY  OF  MISCARRIAGES— BY  SECTIONS 


SECTION 

Percentage  REPORTiNa  Specified  Nitmbbr 

0 

1 

2 

3 

4 

76.6            15.9 
77.4             14.2 

3.9 
6.2 

2.7 

3.0 
1.7 
3.2 

0.6 

Central  China 

0.4 

South  China 

75.1 

17.0 

1.8 

All  China 

76.5 

15.3 

4.8 

1.1 

0.7 

Table  65  shows  that  three-fourths  of  the  wives  have  not 
had  a  miscarriage,  and  of  those  who  have  had,  two-thirds 
have  had  only  one.  There  is  no  great  difference  in  the  number 
by  sections. 


84       The  Health  of  Missionary  Families  in   China 


Table  66 


MISSIONARY   SOCIETIES 

NUMBER  AND  PERCENTAGE  OF  STILLBIRTHS  BY  SOCIETIES 


SOCIETIES 

Stillbirths 

Number 

Number  per  100 
Living  Births 

American  Baptist,  North 

American  Church  Mission 

American  Methodist,  North 

London  Mission 

Y.  M.C.A.- ... 

1 
2 
5 
1 
3 
2 

1.01 
2.56 
2.53 
1.22 
2.50 
.45 

Total,  First  Group ..     . 

14 

1.37 

Canadian  Methodist 

1 
4 
3 
2 
12 
2 

.74 

Church  Missionary  Society 

American  Presbyterian,  North 

American  Lutheran  Societies.. 

4.25 

.95 

1.45 

American  Board  Mission 

4.12 

English  Baptist 

1.45 

Total,  Second  Group 

24 

2.16 

Other  English  Societies .  .  .  . 

........ 

1 

3 

........ 

China  Inland  Mission 

2.89 

American  Presbyterian,  South 

Other  European  Societies . 

.94 

1.75 

American  Baptist,  South 

European  China  Island  Mission . 

2.82 

Total,  Third  Group... 

21 

1.94 

All  Societies 

59 

1.84 

Table  QQ  gives  the  number  of  stillbirths  by  societies.  The 
first  group  has  the  fewest. 

Only  two  (3%)  of  the  stillbirths  occurred  outside  China. 
Cause  of  stillbirth  was  stated  in  only  17  cases,  as  follows: 
difficult  labor,  8;  overwork,  3;  sickness,  4;  fall,  1;  travel,  1. 

In  the  question  blanks  sent  out,  persons  were  asked  to  make  a  check 
mark  in  case  they  did  not  care  to  answer  the  question  concerning  miscar- 
riages. Only  one  or  two  blanks  were  so  checked.  For  the  many  blanks, 
therefore,  on  which  nothing  was  written  in  the  space  for  miscarriages,  it  is 
assumed  that  there  were  none.  Unrecorded  miscarriages  would  lower  the 
miscarriage  rates  below  the  true  figure.  It  is  possible  that  some  of  the 
figures  in  these  tables  should  be  higher  than  they  are. 


CAUSES   OF   MISCARRIAGES 

Table  67  gives  the  parents'  statement  of  the  principal 
causes  of  the  miscarriages,  occurring  in  China,  and  the  num- 
ber of  the  pregnancy  for  each.  Sixteen  of  the  377  are  dupli- 
cates, two  causes  being  assigned  for  one  miscarriage. 

Miscarriages  occur  slightly  later  than  living  births.  35 
per  cent  of  living  births  were  first  births,  while  only  23%  of 
miscarriages  were  first  pregnancies.  Five  per  cent  of  the  liv- 


The  Health  of  the  Children 


85 


Table  67 


CAUSES  OF  MISCARRIAGES  WHICH  OCCURRED  IN  CHINA 


Total 

Number 

OF  M1SCARRUQE8  Occurring  During  Specifibd  Pregnanct 

Ist 

2nd 

3rd 

4th 

5th 

6th 

7th 

8th 

9th 

10th 

Not 
Stated 

Geotiral  Co>n)rriONs 
Overwork- 

65 
37 
11 
10 
9 
7 

10 

6 

.... 

2 
2 

15 
13 
2 

1 

"2 

11 

7 
1 
3 
2 

6 
6 
0 
1 
2 
1 

5 
3 
2 
1 
1 
1 

8 

1 

.... 

3 

1 

.... 

1 

"2" 

--- 

1 

5 

Overexertion  and  Exercise. 
Debility... 

Nervousnesa. .  . 

Revolution .  . 

Fright  and  Anxiety 



Phtsical  Agents 
A  Fall  or  Injury. 

21 
11 
10 
3 
3 
7 

3 
3 
6 
1 
1 
2 

8 
3 
3 

2 

1 

1 
2 

.... 

3 
1 

"2 

2 
"2 

2 
2 



.... 

"V 

- - 

2 

Travel— Cart  or  Barrow... 
—Litter  or  Chair. . . 
— Steamer. 

— Rickshaw 

— Not  Specified 

.... 

Pelvic  Organs  Abnormal.. 

43 

10 

6 

5 

8 

5 

5 

3 



— 

1 



Sickness 
Typhoid 

9 
7 
6 
4 
10 

2 
3 

1 
1 
4 

4 

1 
2 

"3" 

1 

2 

"2 
2 

1 
.... 

.... 

.... 

1 

1 

.::: 

1 

.::: 

;;;; 

:::: 

Eclampsia 

Malaria. .      ... 

Dysentery.. 

1 

Miscellaneous  Causes 

8 
68 
28 

2 
16 
9 

3 

12 
3 

1 

8 
5 

1 
8 
2 

1 
6 
4 

"9" 
3 

"3' 

"2 

1 

.... 

.... 

3 

Cause  Not  Stated 

377 

84 

83 

56 

50 

36 

31 

12 

7 

2 

3 

11 

Percentage  of  Total 

99 

23 

23 

16 

13 

9 

8 

3 

2 

1 

1 

.... 

ing  births  were  sixth  births  or  later,  whereas  15%  of  the  mis- 
carriages were  sixth  pregnancies  or  later. 

Overwork  and  over-exertion  seems  to  cause  later  miscar- 
riages in  larger  proportion  than  travel  or  sickness. 

Eighty-seven  per  cent  (362  out  of  416)  of  all  miscarriages 
occurred  in  China.  Eighty-two  per  cent  of  married  years  were 
spent  in  China.  Therefore  miscarriages  were  slightly  more 
frequent  in  China  than  at  home. 

Table  68  compares  the  cause  of  miscarriage  (in  the  cases 
in  which  a  cause  was  assigned)  in  China  and  out  of  China. 

In  spite  of  the  fact  that  27  of  the  55  miscarriages  due  to 
physical  injuries  in  China  were  thought  due  to  peculiar  modes 
of  travel  (cart,  rickshaw,  etc.)  an  even  higher  percentage  of 
this  class  of  miscarriages  occurring  at  home,  i.e.,  8  out  of  11, 
were  assigiied  to  travel  as  a  cause.  Practically  one-half  of  all 
miscarriages,  in  the  opinion  of  the  persons  themselves,  were 
due  to  overwork,  debility,  nervousness,  fright,  etc. 


86       The  Health  of  Missionary  Families  in   China 


Table  68            SUMMARY  OF  PRINCIPAL  CAUSES  OF  MISCARRIAGE,  OCCURRING  IN  AND 

OUTSIDE  OF  CHINA 

CAUSE  OF  MISCARRUGE 

OCCURRING  IN  CHINA 

OCCURRING  OUTSIDE 
CHINA 

Number  of 
Miscarriages 

Per  Cent  of 
Total 

Number  of 
Miscarriages 

Per  Cent  of 
Total 

139 
55 
43 
36 

49 
21 
10 
14 

21 
11 
5 
6 

49 

25 

11 

16 

Total     - 

273 

100 

43 

100 

Twenty-five  per  cent  of  miscarriages  in  China  were 
blamed  on  "overwork,"  while  30%  of  those  occurring,  at  home 
were  laid  at  the  same  door.  This  would  indicate  that  furlough 
is  not  a  time  of  rest  and  recuperation  for  the  wife,  but  one  ot 
increased  labor. 


CONDITIONS  OTHER  THAN  HEALTH 

The  welfare  of  children  involves  many  more  considera- 
tions than  those  of  physical  health.  Though  this  study  does 
not  attempt  to  deal  with  these,  their  importance  should  be 
recognized. 

In  some  points,  such  as  long  separation  from  parents, 
lack  of  contact  with  large  groups  of  other  children,  scarcity 
of  high  grade  schools,  missionary  children  are  the  losers.  In 
other  no  less  important  respects,  such  as  growth  in  an  atmos- 
phere of  religion  and  service,  intimate  family  life,  freedom 
from  the  dangers  of  our  too  complex  social  life  (including 
attendance  on  moving  picture  shows),  the  broad  education 
of  travel,  the  growth  of  the  cosmopolitan  outlook,  missionary 
children  are  the  gainers.  The  social  and  religious  condition 
of  adult  children  of  missionaries  w^ould  make  an  interesting 
study. 

The  pictures  on  the  two  following  pages  show  groups  of 
missionary  children  in  Peking.  The  majority  are  children  of 
doctors.  All  of  the  third  group  have  had  protective  inocula- 
tion against  typhoid,  paratyphoid,  and  diphtheria. 


Prospective  missionary  candidates — celebrating  a  birthday,  at  the  Zon 


Missionary  children  have  the  finest  of  playmates — other  missionary  children. 
They  do  not  always  have  as  good  a  play  place  as  have  these  children 


The  camel  train  has  arrived,  witli  sod  for  the  playground.   Children  in  China 
see  many  interesting  things  denied  to  their  stay-at-home  relatives 


A    tree    about    which    missionary    children    have 

played    for    fifty    years — the    only    object    in 

the  compound  left  standing  by  the  Boxers 


The  Health  of  Married  Adults  87 


PART  II  —  Health  of  Married  Adults 
INTRODUCTION 

This  study  is  concerned  principally  with  children  because 
(1)  of  the  writer's  interest  in  missionary  children  and  because 
of  the  lack  of  any  previous  study  of  them,  (2)  because  the  ques- 
tionnaire method  is  applicable  for  the  collection  of  mortality 
statistics  concerning  children,  as  it  is  not  for  adults  (since 
most  families  in  which  a  parent  has  died  are  not  now  on  the 
mission  rolls),  and  (3)  because  the  study  of  the  adult  body  is 
too  large  an  undertaking  for  one  person. 

It  is  realized  that  the  good  health  of  adults  is  of  more 
importance  to  the  missionary  cause  than  the  good  health  of 
children.  The  writer  has,  in  a  previous  paper"^  presented 
some  of  the  reasons  for  modern  medical  care  of  the  missionary 
body.  It  is  encouraging  to  note  that  some  of  the  boards  have 
undertaken  the  study  of  the  health  of  their  workers  (see  pages 
95  and  112).  Such  studies  are,  however,  rare  and  it  seems 
worth  while  to  present  such  facts  concerning  adults  as  are 
furnished  by  this  questionnaire. 

Fifteen  hundred  and  seventy-seven  adults,  about  60%  of 
those  who  returned  the  question  blanks,  made  statement  con- 
cerning their  own  health.  These  had  spent  some  17,600  years 
in  China,  during  which  time  they  had  contracted  nearly  1,500 
cases  of  sickness. 

There  are  some  duplications  due  to  the  fact  that  some 
parents  are  also  children  of  missionaries  still  on  the  field. 
Though  a  number  of  these  duplicates  have  been  eliminated, 
probably  a  few  remain. 


88       The  Health   of  Missionary  Families  in   China 

FACTS   CONCERNING  RESIDENCE  AND   MARRIAGE 

Table  69  (based  on  1,064  reports)  shows  the  average 
length  of  married  life  and  the  proportion  spent  in  China. 
Those  in  the  north  have  been  married  longer  than  those  in 
the  south.  The  proportion  of  married  life  spent  in  China  is 
nearly  the  same  for  the  three  sections. 


Table  69 


AVERAGE  NUMBER  OF  MARRIED  YEARS  AND  PROPORTION 
SPENT  IN  CHINA— BY  PROVINCES. 


PROVINCE 

Number 
Reporting 

Total 

Since 

Marriage 

No.  Married 

Years  In 

China 

Average  No.  Married 
Years 

Per  Cent  of 

Married  Life 

In  China 

Since 
Marriage 

In 
China 

Manchuria . 

23 
77 
101 
25 
23 

264 
1166 
1098 
330 
335 

337 
890 
883 
277 
299 

11.4 
15.1 
10.9 
13.1 
14.5 

10.3 
11.6 
8.7 
11.1 
13.0 

90 

76 

Chihli... 

80 

84 

89 

North  China.  -      

297 

3744 

3006 

12.6 

10.1 

80 

Kiangsu 

150 
26 
71 
64 
23 
62 
67 
9 
99 

1858 
392 
672 
932 
289 
660 
550 
128 

1127 

1517 
323 
593 
801 
241 
561 
430 
121 
913 

12.4 
15.0 

9.5 
14.5 
12.6 
10.6 

8.2 
14.2 
11.4 

10.1 
10.9 

8.3 
12.5 
10.5 

9.0 

6.4 
13.5 

9.2 

73 

Anhwei . 

72 

Honan _ 

88 

Chekiang...          .  .  .  .  . 

86 

83 

Hupeh- 

85 

Hunan .  .  .  .  . 

78 

95 

Szechuan.  . 

81 

Central  China 

571 

6608 

5500 

11.5 

9.6 

83 

168 

110 

18 

727 

1216 

64 

570 
971 
49 

10.7 
11.0 
8.0 

8.4 
8.9 
6.2 

73 

80 

Yunnan. 

77 

South  China 

196 

2007 

1590 

10.2 

8.1 

79 

All  China. 

1064 

12359 

10096 

11.6 

9.4 

81 

Table  69  referred  to  Married  years.  Table  70  gives  the 
years — whether  married  or  unmarried — spent  in  China.  Since 
the  average  years  in  China  are  11.2,  and  the  married  years 
but  9.4,  many  persons  must  have  been  married  after  being  on 
the  field  for  a  period.  Here,  as  in  Table  69,  the  missionaries 
in  North  China  have  been  the  longer  on  the  field.  This  would 
indicate  that  the  average  missionary  life  in  South  China  is 
shorter  than  in  the  north  by  20%. 

This  proportion  holds  good  for  both  married  years  and 
total  years.  Not  only  have  couples  in  North  China  been  in 
China  longer,  but  also  they  have  been  married  longer.  This 
means  that  the  percentage  of  married  life  spent  in  China  is 
about  the  same  for  the  three  sections.  Married  years  in  China 
are  exclusive  of  periods  in  which  both  parents  were  on 
furlough. 


The  Health  of  Married  Adults 


89 


Table  70 


AVERAGE  NUMBER  OF  YEARS  ADULTS  (NOW  MARRIED)  HAVE 
BEEN  RESIDENTS  IN  CHINA— BY  PROVINCES 


PROVINCE 

Number  I 

uEPORTINQ 

Av.  Yr3. 

m  China 

Total 
Husband  and  Wife 

Total 
Years 

Husband 

Wife 

Husband 

Wife 

Number 
Reporting 

Av.  Yrs. 
in  China 

10 
42 
63 
34 
16 
15 

12 
46 
62 
32 
13 
15 

10.9 

12.9 

11. 

12.8 

10.8 

16.5 

9.2 
13.4 
10.4 
11. 

9.8 
17.1 

22 
88 
125 
66 
29 
30 

10. 

13.3 

10.7 

11.9 

10.3 

16.8 

222 
1171 
1338 
788 
316 
497 

Shantung 

Chihii 

Shansi .       .... 

Shensi... . 

Kansu 

North  China        . .  - 

180 

180 

12.5 

11.8 

360 

12.2 

4388 

Kiangsu  

86 
13 
22 
49 
26 
28 
36 
32 
62 

88 
9 
22 
45 
35 
21 
38 
31 
54 

11 

17.3 
16. 
11.5 
12.2 
14. 
8.1 
11.5 
12.3 

9.8 
14. 
15.2 

9.8 
14. 
11.8 

7.7 

9.6 
12.3 

174 
22 
44 
94 
61 
49 
74 
63 

116 

10.4 
16. 
15.6 
10.6 
13.1 
13.2 
7.9 
10.6 
12.3 

1817 
351 
687 

1004 
791 
638 
583 
667 

1426 

Anhwei... 

Chekiang. . 

Honan .....  ...... 

Kiangsi 

Hupeh ... 

Hunan .... . 

Kueichow ...  

Central  China 

354 

343 

11.8 

10.9 

697 

11.4 

7933 

50 
76 
5 

42 
73 

8 

8.1 
10.5 
21. 

9.4 
9.5 
12.6 

92 

149 

13 

9.7 
10. 
15.8 

805 
1497 
207 

South  China.  ..  

131 

123 

10. 

9.5 

254 

9.8 

2494 

For  All  China        

665 

646 

11.6 

10.8 

1311 

11.2 

14663 

Table  71 


NUMBER  OF  YEARS  ADULTS  (NOW  MARRIED)  HAVE 
BEEN  RESIDENTS  IN  CHINA— BY  PROVINCES 


PROVINCE 

Number  Resident  in  China  Specified  Number  of  Years 

0-5 

6-10 

11-15 

16-20 

21-25 

26-30 

31-35 

35-39 

Total 

3 
19 
49 
21 
4 
2 

9 
23 
23 
12 
10 

4 

8 
14 
15 
13 
4 
4 

2 
11 
17 
10 
4 
5 

1 
9 
9 
3 
2 
5 

"io' 

5 
5 
2 
5 

"2 

7 

.... 

23 
88 
125 

Shantung 

ChihJi...           

65 
26 

25 

North  China 

98 

81 

58 

49 

29 

27 

9 

1 

352 

55 

6 

8 

37 

2 

21 

24 

17 

49 
2 
4 
15 
24 
5 

60 
44 

25 

"Y 

15 
20 
1 
37 
24 

29 
3 

13 

13 
7 
8 
7 

13 

13 
8 
8 

10 
5 
9 
5 

11 

4 
3 
2 
2 
2 
1 
2 
3 

1 

"2 

1 
1 

"2 

"2 

176 

22 

44 

94 

61 

46 

135 

114 

170 

203 

129 

93 

69 

19 

7 

2 

692 

36 
46 

24 
53 

19 
31 

10 
15 

3 
4 

3 
6 

""3" 

95 

158 

82 

77 

50 

25 

7 

9 

3 

.... 

253 

All  China— Husband 

Wife 

167 
183 

172 
189 

132 
105 

82 
85 

64 
41 

30 
25 

13 
6 

2 
1 

662 
635 

All  China— Husband- 
and  Wife. 

350 

361 

237 

167 

105 

55 

19 

3 

1297 

90       The  Health   of  Missionary  Families  in   China 

Table  71  presents  the  number  of  years  adults  have  been 
resident  in  China,  exclusive  of  time  on  furlough,  by  provinces. 
Fifty-five  per  cent  have  been  in  China  ten  years  or  less,  and 
but  13%  for  20  years  or  more.  Table  70  showed  that  wives 
had  spent  7%  less  time  in  China  than  their  husbands.  This 
table  shows  that  the  wives  who  have  been  in  China  ten  years 
or  less  are  relatively  more  numerous  than  the  husbands. 


Table  72 


NUMBER  AND  YEARS  OF  MARRIED  LIFE  AND  PERCENTAGE 
OF  MARRIED  LIFE  SPENT  IN  CHINA— BY  SOCIETIES 


Total  No.  Married  Years 

Number  Married  Years 
Spent  in  China 

Per  Cent 
OF  Mar- 
ried Yrs. 

SOCIETY 

No.  Fam- 
ilies Re- 
porting 

No.  of 
Years 

Average 
No.  of 
Years 

No.  Fam- 
ilies Re- 
porting 

No.  of 
Years 

Average 
No.  of 
Years 

IN  China 

American  Baptist,  North.. 

44 

518 

11.7 

44 

403 

9.1 

77 

American  Church  Mission. . 

44 

335 

7.6 

38 

185 

4.8 

55 

Am.  Methodist,  North 

73 

961 

13.1 

72 

824 

11.4 

85 

34 

426 

12.5 

29 

287 

9.8 

91 

Y.  M.C.A..-. 

63 

465 

7.3 

63 

290 

4.6 

62 

Other  American  Societies.  . 

22,5 

2194 

9.7 

214 

1613 

7.5 

73 

4S1 

4S99 

10.2 

453 

3436 

7.5 

70 

Canadian  Methodist 

47 

437 

9.2 

45 

316 

7.02 

72 

Church  Miss.  Society. 

38 

431 

11.4 

30 

335 

11.1 

81 

Am.  Presbyterian,  North.. 

125 

1532 

12.2 

113 

1254 

11.09 

82 

Am.  Lutheran  Societies 

53 

353 

6.6 

46 

264 

5.7 

75 

Am.  Board  Mission  _ 

51 

607 

11.9 

51 

479 

9.4 

77 

34 

400 

11.7 

29 

209 

7.1 

52 

Total  2nd  Group 

34S 

3756 

10.9 

314 

2856 

9.1 

76 

Other  English  Societies 

103 

1398 

13.4 

97 

1112 

11.4 

79 

China  Inland  Mission 

151 

2091 

13.8 

139 

1733 

11.7 

82 

Am.  Presybterian,  South.  . 

28 

436 

15.5 

28 

382 

13.6 

87 

Other  European  Societies. . 

63 

720 

11.4 

61 

607 

10.0 

84 

Am.  Baptist,  South 

41 

638 

15.5 

38 

448 

11.7 

70 

European  C.  I.  M 

41 

484 

11.8 

38 

399 

10.5 

82 

Total  3rd  Group 

429 

5768 

13.5 

406 

4681 

11.5 

81 

Societies  Not  Stated 

2 

28 

14. 

2 

26 

13. 

92 

Total 

1259 

14450 

11.4 

1179 

10996 

9.3 

77 

MARRIED;  years  not 
stated  (average  taken) 

40 

456 

11.4 

122 

1133 

9.3 

Grand  Total 

1300 

14906 

11.4 

1300 

12132 

9.3 

81 

The  Health  of  Married  Adults  91 

Table  72  (based  on  1,300  reports)  shows  the  married 
years,  and  the  portion  spent  in  China  according  to  societies, 
arranged  in  the  order  of  child  mortality,  the  lowest  at  the  top. 
For  the  three  big  groups,  child  mortality,  as  has  been  seen, 
varies  with  the  average  age  of  the  children. 

This  table  shows,  as  one  would  expect,  that  mortality 
varies  also  with  the  length  of  time  of  marriage.  It  also  shows 
(last  column)  that  mortality  for  the  big  group  varies  in- 
versely with  the  time  spent  on  the  field,  i.e.,  the  first  group, 
in  which  parents  have  spent  only  seven  of  ten  married  years 
on  the  field,  have  a  lower  rate  than  the  group  which  have  spent 
eight  out  of  ten.  This  may  mean  that  the  first  group  has  had 
more  frequent  furloughs,  or  a  larger  period  of  marriage  be- 
fore coming  to  the  field. 

A  separate  tabulation  (table  not  printed)  for  families 
with  and  without  children,  shows  that  families  with  children 
of  group  1  have  been  married  10.7  years;  of  group  2,  11.3 
years,  and  of  group  3,  13.5  years.  Those  without  children 
have  been  married  only  about  half  this  number  of  years. 

MORTALITY   AMONG   ADULTS 

As  has  been  explained,  this  questionnaire  method  is  of  no 
value  for  arriving  at  a  mortality  rate  for  adults.  However, 
the  list  of  diseases  of  which  parents  have  died  is  of  interest. 
Of  72  married  adults  who  had  died,  the  following  are  the 
stated  causes  of  death.  Dysentery,  9;  typhoid,  6;  cancer,  6; 
tuberculosis,  5 ;  childbirth,  5 ;  4  each  of  smallpox,  typhus,  and 
malaria ;  3  each  of  pneumonia,  puerperal  fever,  cholera,  sprue, 
and  kidney  disease;  2  each  of  apoplexy,  heart  trouble,  and 
appendicitis,  and  1  each  of  fever,  sunstroke,  blood  poisoning, 
hemorrhage,  operation,  meningitis,  diarrhoea,  and  urasmia. 
Fifty — more  than  two-thirds — were  due  to  infections.  Eight 
mothers  died  of  diseases  caused  by  confinement,  of  whom 
three  died  of  childbirth  fever. 

Of  missionaries  who  died  during  1917,  as  reported  by  the  China  Mission 
Year  Book,  28  of  the  56  deaths  in  which  cause  of  death  was  recorded,  died  of 
infectious  diseases.  The  list  includes:  typhus  fever,  5;  typhoid  fever,  4; 
dysentery,  3;  smallpox,  2.  An  interesting  fact  is  the  comparative  immunity 
enjoyed  by  missionaries  in  China  during  the  influenza  pandemic  of  that 
year.  30%  of  missionaries  dying  outside  of  China  died  of  influenza,  whereas 
only  2%  (viz.,  one)  of  those  dying  in  China  succumbed  to  that  disease. 

MORBIDITY   AMONG   ADULTS 

Table  73  shows  the  number  of  illnesses  in  order  of  fre- 
quency for  husband  and  wife  by  provinces. 


92       The  Health   of  Missionary  Families  in   China 


Table  73 


GEOGRAPHICAL   LOCATION 

INCIDENCE  OF  PRINCIPAL  INFECTIONS  AMONG  ADULTS  BY  PROVINCES 


PROVINCE 

SICKNESSES 

CO 

5 
la 
1 

a 

3 

a 

"a 

CO 

1 

.a 

CO 

1 

2 

1 

a 
< 

d 
0 

60 

'■% 
0 

W 

D. 

0 

ja 
% 

a 

03 

a 
X 

e 

3 
ja 

CO 

3 

a 
<a 

3 
3 

Number  or  Persons  Reporting 

Male 

17 

63 

77 

40 

15 

18 

101 

16 

41 

53 

17 

41 

59 

74 

54 
55 

91 

Female. -- 

16 

65 

81 

42 

15 

18 

106 

17 

43 

57 

18 

45 

59 

74 

89 

Total... 

33 

128 

158 

82 

30 

36 

207 

33 

84 

110 

35 

86 

118 

148 

109 

180 

Numi 

3ER  OF  Cases  op  Sickness  per  100  Persons 

Total— All 
Sicknesses 

Male 

Female... 
Both  ... 

102 
96 

87 

56 
71 
63 

56 
69 
62 

55 
69 
61 

48 
34 
40 

94 
50 
72 

86 
105 
95 

100 
65 

82 

85 
81 
85 

99 
65 
81 

147 
156 
151 

112 
69 
89 

105 
106 
106 

65 
54 
60 

78 
71 
74 

100 

85 
93 

Total  of  Sick- 
nesses Listed 
Below 

Male 

Female... 
Both... 

90 
60 
75 

56 
59 
57 

50 
49 
50 

52 
52 
52 

42 
14 
24 

85 
25 
54 

82 
88 
85 

94 
53 
73 

79 
49 
63 

92 
51 
70 

135 
130 
131 

106 
66 

88 

102 
95 
98 

61 
48 
54 

74 
65 
68 

92 

84 
88 

Malaria 

Male 

Female... 
Both... 

6 
6 
6 

8 
5 
6 

6 
5 
5 

7 
7 
7 



30 
12 
21 

21 
30 
25 

48 
24 
36 

29 
5 
17 

45 
23 
34 

59 
55 
57 

30 
20 
25 

25 
20 
22 

20 
8 
14 

27 
23 
25 

35 
32 

3 

Dysentery 

Male 

Female... 
Both... 

30 
18 
24 

17 
14 
15 

13 

7 
10 

17 
12 
15 

13 
13 
13 

18 
6 
11 

14 

18 
16 

24 
"12" 

17 

24 
21 

19 
7 
13 

29 
17 
23 

37 

9 

25 

35 

27 
32 

16 
7 
12 

9 
9 
9 

17 
12 
15 

Typhoid  Fever 

Male..... 
Female... 
BotJi ... 

24 
19 
22 

6 
9 

7 

12 
2 
7 

5 

7 
6 

7 
""4" 

22 
6 
14 

7 
9 

8 

6 
18 
12 

10 

7 
8 

5 
""3' 

12 
22 
17 

15 
9 
12 

10 
10 
10 

12 
9 
10 

9 
2 
5 

5 
3 
4 

Nervous  Break- 

Male 

Female... 
Both... 

6 
12 
9 

1 
6 
3 

1 

5 
3 

7 
2 
4 

9 
4 

7 

3 

2 
2 
2 

5 
7 
6 

:::: 

7 
5 
6 

5 

10 

7 

3 
6 
4 

2 
2 
2 

7 

7 

7 

Male..... 
Female. . . 
Both... 



8 
5 
6 

8 
6 
7 

2 
5 
3 

7 

6 

6 
5 
5 

6 
"3" 

2 
2 
2 

2 
4 
3 

— 

7 
7 
7 

5 
2 
3 

1 
1 

1 

6 
6 
6 

4 
3 

3 

3 

3 

Male 

Female.. - 
Both... 

24 
"l2 

"I' 

2 

3 
4 
3 

4 
4 
4 

.... 

2 

2 
2 
2 

12 

28 
20 

5 
"'2" 

5 

7 
6 

4 
3 
3 

4 
8 
6 

7 

Diarrhea,  etc 

6 

.... 

1 

6 

Male 

.... 

5 

3 

1 
2 

2 
2 
2 

6 
5 
5 

3 

2 
.... 

5 
4 
5 

6 

.... 

2 
3 
3 

.... 

1 

13 
11 
12 

8 

Roundworms 

7 

Botn  ... 

.... 

3 

3 

.... 

8 

Male 

Female. -. 
Both.... 

:::: 

1 
5 
3 

3 
3 
3 

1 
5 
3 

3 

5 
3 
4 

5 
4 
4 

.... 

5 

"2 

1 

5 

2 
4 

12 
3 

1 
1 

1 

1 
1 

3 

4 
6 
5 

5 
2 

2 
5 
3 

5 
7 
6 

2 

7 
3 

5 

"2" 

5 
2 
3 

5 
2 

3 
5 

4 

7 
4 

4 

4 
2 

2 

7 

.... 

2 

4 

6 
""3" 

""5' 
3 

Appendicitis 

Operation 

Female.. - 
Both  ... 

6 
3 

6 
3 

6 

mi 

1 

2 

1^ 

1 

Male 

Female.-. 
Botn  ... 

3 

1 

1 

1 
3 
2 

2 

3 

2 

7 

6 

5 
2 
3 



— 

3 
3 
3 

3 
2 
2 

4 

Male 

1 

Typhus  Fever 

Botii_._ 

Hi: 

1 

3 

3 

2 

h:: 

1 

2 
.... 

6 
6 
6 

"Y 
3 

4 

Tuberculosis 

Female... 
Botn  ... 



1 
1 

1 

1 

1 

1 

1 

.... 

2 

Male 

2 

1 
2 

.... 

2 
2 
2 

3 

2 

2 

1 

Female... 
Both  ... 

.... 

1 

1 

4 

2 

2 
1 

1 

1                  1 

The  Health  of  Married  Adults 


93 


Since  many  did  not  state  ages  or  years  of  residence,  the 
reckoning,  is  on  the  basis  of  the  number  of  persons.  This  is  a 
bit  unfair  to  the  Northern  provinces,  since  the  adults  in  the 
North  have  averaged  more  years  in  China  than  those  in  the 
South.  As  in  the  similar  table  for  children,  the  recorded  num- 
ber of  illnesses  from  malaria,  dysentery,  diarrhoea,  round 
worms,  etc.,  is  far  below  the  actual  number,  since  many  rein- 
fections are  not  recorded. 

It  will  be  noted  at  once  that  the  distribution  of  certain 
diseases  is  not  the  same  as  for  the  children.  Acute  intestinal 
infections,  dysentery,  diarrhoea  and  typhoid  are  relatively 
more  common  in  Central  China  than  was  the  case  with  the 
children.  This  is  especially  true  of  dysentery.  The  fact  that 
bacillary  dysentery  is  more  prevalent  in  the  north  and  amebic 
dysentery  in  the  south  may  have  something  to  do  with  this 
phenomenon.  The  rarity  of  amebic  dysentery  among  Filipino 
children  has  been  noted  by  Haughwout.'^ 

A  needed  piece  of  research  is  an  investigation  into  the 
incidence  of  the  two  types  of  dysentery  among  the  Chinese, 
both  adults  and  children,  and  for  the  various  sections  of  China. 


-^    OF  TOTAL        MiiiDlA  DY.FMTKILY        TYPHOID  NtHVOUS        INTESTIMW.     5  p 

ILLNCSIES       '^*'-*'<-'*         DY3ENTER.Y       TYPHOID       6^^;^,^  po„H     iNTtCTlONS     ^**''^^<^°^ 


Figure  38.     Number  of  various  sicl^nesses  per  100  married  mis- 
sionaries by  sections.     (Illustrating  part  of  Table  74.) 


Table  74  is  a  compression  of  Table  73  into  groups  of 
provinces.  The  distribution  of  the  principal  diseases  is  illus- 
trated in  Figure  38. 


94       The  Health  of  Missionary  Families  in   China 


Table  74 


NUMBER  OF  SICKNESSES  PER  100  MARRIED  MISSIONARIES,  IN 
ORDER  OF  FREQUENCY— BY  SECTIONS 


SEX 

North 
China 

Central 
China 

South 
China 

AU  China 

Number  op  Pehsons  Rbportino 

SICKNESSES 

Male 

230 

402 

145 

777 

Total 

Number 

Female 

237 

419 

144 

800 

of 

Total 

467 

821 

289 

1577 

NUMBHU 

OP  Sicknesses  per  100  Persons 

Male 

60 
66 
63 

92 

84 
88 

92 
86 

89 

83 
76 
81 

644 

Total— All  Sicknesses- 

Female 

Both 

630 

1274 

Male -. 

59 
49 
52 

88 
71 
79 

81 
76 
80 

79 
66 
72 

606 

Female  . 

524 

Both 

1130 

Male....      .... 

8 
5 
7 

29 
21 
25 

32 

28 
30 

23 

18 
21 

182 

Malaria . 

Female 

144 

Both.. 

326 

Male 

16 
11 
13 

22 
14 
IS 

14 
11 
13 

19 
13 
15 

149 

Dysentery. . 

Female 

103 

Bach          

250 

Male - 

10 
6 

8 

9 
8 
9 

8 
3 
5 

7 
7 

8 

72 

Typhoid  Fever.  _. 

55 

Both.  .     

127 

Male-  - - 

3 
5 
4 

5 
5 
5 

5 

5 
5 

4 
5 
5 

34 

Female. 

40 

Both 

74 

Male... 

6 
4 
5 

4 
3 
3 

0 

4 

4 

5 
4 
4 

37 

Influenza _                  .       

Female 

29 

Both 

66 

Male.... 

3 
3 
3 

4 
4 

4 

6 
6 
6 

4 

31 

4 

4 

31 

Both 

62 

Male.... 

3 
1 

2 

3 
3 
3 

12 
9 
10 

4 
3 
4 

33 

Roundworms.   .  .  . 

Female. 

25 

Both 

58 

Male-... 

...... 

2 

2 
4 
3 

...... 

3 

1 
4 
2 

10 

Sprue ... 

Female 

29 

Both  ...  

39 

Appendicitis  Operation 

Male 

Female 

2 
2 

2 

3 
3 
3 

1 
1 
1 

2 
2 

17 
19 

Botn - 

36 

Male 

1 

1 
1 
1 

1 

1 
1 
1 

5 

Scarlet  Fever 

Female 

9 

Both... 

14 

Male. _ 

1 
4 
3 

2 
1 
2 

2 

1 
1 

2 
2 

2 

11 

Smallpox 

Female. _.. 

Both 

17 

28 

4 
2 
3 

2 

1 
2 

1 

2 
1 

2 

19 

Typhus  Fever...    

Female 

11 

Both 

30 

1 

2 

1 
1 

1 
3 

2 
1 
2 

8 

12 

Both 

20 

The  Health  of  Married  Adults 


95 


Malaria  and  dysentery  are  more  frequent  among  men 
than  women.  This  may  be  because  of  greater  conscientious- 
ness on  the  part  of  the  wives  in  guarding  against  infection, 
or  because  they  do  not  travel  about  so  much  as  their  husbands. 
Also,  the  wives  have  not  been  in  China  as  long  as  their  hus- 
bands. (Table  71.)  Spnie  is  much  more  prevalent  among 
wives.  Nervous  breakdowns  are  only  slightly  more  frequent. 
(Figure  39.) 

In  addition  to  the  cases  of  sickness 
listed  in  the  table,  the  following  causes  of 
sickness  among  married  missionaries 
were  named:  Pelvic  operations,  41;  puer- 
peral fever,  11;  eclampsia,  9;  obstetric 
disaster,  4;  ectopic  pregnancy,  2;  pneu- 
monia, 21;  cholera,  14;  heart  disease,  12; 
kidney  disease,  12;  diphtheria,  11;  can- 
cer, 8;  dengue,  8;  meningitis,  4;  tape- 
worm, 3;  trachoma,  2;  paralysis,  2;  dia- 
betes, 2,  and  one  each  of  relapsing  fever, 
plague,  angina  pectoris,  progressive  mus- 
cular atrophy,  syphilis  (a  surgeon  in- 
fected during  an  operation),  apoplexy, 
sunstroke,  anaemia.     Total,  174. 

The  diseases  named  in  Tables  73  and 
74  refer  only  to  those  contracted  in  China 
Besides  these,  162  were  named  as  con 
tracted  at  home,  as  follows:  Scarlet  fever 
39;  typhoid,  37;  pneumonia,  20;  appendi 
citis,  16;  nervous  breakdown,  13;  malaria,  12;  diphtheria,  10;  tuberculosis 
4;  smallpox,  3;  heart  disease,  2;  influenza,  2,  and  one  each  of  kidney  disease 
meningitis,  dysentery,  and  sprue. 

So  few  of  the  correspondents  put  down  their  ages,  that  a  general  com- 
parison of  morbidity  in  China  and  at  home  on  the  basis  of  years  of  residence 
is  impossible. 

Table  75  shows  the  number  and  proportion  of  Church 
Missionary  Society  missionaries,  as  reported  by  Price,"  inva- 
lided home  from  the  sections  of  China.  Neurasthenia  (nerv- 
ous breakdoAvn)  is  by  far  the  most  common  cause.  Contrary 
to  statistics  of  this  study,  it  is  much  more  frequent  in  North 
China. 


Figure  39.  Incidence  of  cer- 
tain sicknesses  among  hus- 
bands and  wives.  (Illustrat- 
ing part  of  Table  74.) 


Table  75 


CAUSES  OF  INVALIDING  OF  203  CHURCH  MISSIONARY  SOCIETY 
MISSIONARIES. 


SICKNESS 

North 
China 

Centra! 
China 

South 
China 

All 
China 

Per  Cent 

Per  Cent 

Per  Cent 

Per  Cent 

44.3 
.■Jl 

13.8 
8.6 
5.1 
5.1 

58"" 

17.7 
12.6 
7.6 
11.4 
7.6 
8.8 
5. 
2.5 
3.8 

79"" 

10.6 
7.5 
7.5 

15. 
3. 

18. 

"4".5 

"3"' 
66. 

25. 

Insanity -       -  -  

8.8 

9.8 

Malaria  _     ...       -_... 

11.8 

5.9 

10.8 

Typhus  Fever.  .  ..  .  -  .  .  .  

1.9 

2.9 

Smallpox  __                .--...  

1.4 

.9 

203. 

96       The  Health  of  Missionary  Families  in   China 


PERIOD   WHEN   SICKNESSES   ARE   CONTRACTED 

The  attempt  is  made  in  Table  76  to  ascertain  the  danger 
period  for  various  diseases. 

The  date  of  infection  had  to  be  calculated  from  the  age  of 
the  person,  the  age  at  time  of  infection  and  number  of  years 
in  China.  This  roundabout  method  gives  opportunity  for 
error.  Also  the  number  of  cases  in  which  the  necessary  data 
was  given  is  small.  Second  or  subsequent  attacks  are  included. 
The  numbers  should  be  compared  with  the  bottom  line,  which 
gives  the  number  of  missionaries  who  have  spent  the  specified 
year  in  China.  Few  questionnaires  reached  those  who  had 
been  less  than  a  year  in  China. 


Table  76 


MARRIED  MISSIONARIES— NUMBER  OF  YEARS  AFTER  ARRIVING 
IN  CHINA  WHEN  SICKNESSES  WERE  CONTRACTED. 


Number  op 

Sicknesses  in 

Specified  Year  After  Arrival 

SICKNESS 

0-1 

1 

2 

3 

4 

5-9 

10-14 

15-19 

20-24 

25- 

All 
Years 

Dysentery 

22 
17 
27 
8 

22 
7 

16 
4 
2 
4 
2 

20 

"ll" 

4 
3 
3 
2 

11 

5 
11 

1 
...... 

9 
2 
10 
1 
2 
9 
3 

32 
20 
31 

1 
6 
5 
6 

14 

8 
16 

3 
5 
2 

1 
1 

1 

134 

Typhoid  Fever 

66 

Malaria .  . 

129 

Smallpox. 

20 

Typhua  Fever    . 

5 
3 
5 

2 
1 

2 

20 

Nervous  Breakdown 

5 
1 

1 

34 

Sprue 

21 

Total 

80 

57 

47 

31 

36 

101 

51 

15 

5 

1 

404 

Number  of  Missionaries 

1278 

1229 

1159 

1074 

1005 

627 

367 

211 

81 

Smallpox  is  defijiitely  more  common  immediately  after 
arrival  in  China.  Other  infections  show  the  same  thing  in  less 
marked  degree.  Only  54%  of  the  sicknesses  named  were  con- 
tracted after  three  years  in  China,  though  84%  of  the  mis- 
sionaries have  been  in  China  more  than  that  length  of  time. 

This  decreasing  morbidity  may  be  due  either  to  increas- 
ing immunity  to  disease,  or  to  increasing  knowledge  and  care 
in  prevention.  It  should  be  noted,  however,  that  long  resi- 
dence does  not  confer  immunity.  Infections  are  common  after 
the  fifth  year. 

Of  the  typhoid  cases,  36%  occurred  in  the  first  three  years 
on  the  field.  Among  British  missionaries"  from  all  mission 
fields,  of  187  cases  of  typhoid,  about  half  occurred  during  the 
first  three  years  and  70%  during  the  first  six  years. 


The  Health  of  Married  Adults 


97 


PROPORTION    WITHOUT    SERIOUS    SICKNESS 


Table  77 


PERCENTAGE  OF  HUSBANDS  AND  WIVES  WHO  HAVE  NOT  HAD 
ANY  IMPORTANT  SICKNESS  WHILE  LIVING  IN  CHINA. 


PROVINCE 

Number 

Returning  Question 

Blanks 

Per  Cent  Who 

Answered  Queslion 

ConcerninR  Personal 

Health 

Of  Those 

Answering,  Per  Cent 

Who  Had  Not  Been 

Seriously  Sick 

Husband 

Wife 

Husband 

Wife 

Husband 

Wife 

Manchuria 

26 
95 
107 
55 
26 
26 

26 
97 
109 
57 
26 
26 

65 

65 
72 
72 
58 
70 

01 
67 
71 
74 
58 
70 

65 
52 
61 
50 
60 
33 

56 

Shantung...        .     . ....          

50 

Chihli 

55 

Phansi 

52 

Sheasi-  -.        .-     .----.. 

66 

55 

North  China              

335 

341 

70 

70 

55 

54 

158 
30 
73 
83 
32 
65 
74 
9 

112 

160 
28 
74 
84 
31 
70 
74 
9 

113 

64 
53 
56 
64 
56 
63 
68 
88 
66 

66 
60 
56 
67 
58 
64 
68 
88 
66 

45 
44 
21 
60 
28 
24 
35 
50 
65 

45 

47 

33 

Honan 

51 

5 

44 

33 

50 

58 

636 

643 

63 

65 

41 

44 

75 

123 
9 

76 

126 

9 

72 
67 
55 

72 
60 
55 

47 

48 
40 

43 

48 

212 

211 

68 

68 

47 

45 

All  China 

1183 

1171 

65 

68 

47 

47 

Figure  40.  Percentage  of  mar- 
ried missionaries  who  have 
not  had  serious  sicknesses 
while  living  in  China,  by 
sections.  (Illustrating  Ta- 
ble 77.) 


We  have  seen  that  sickness 
among  adults  is  more  frequent  in 
Central  and  South  China  than  in 
North  China.  This  tabulation  in- 
cluded some  minor  ailments.  Also 
some  of  the  persons  had  had  sev- 
eral different  diseases. 

Table  77  shows  what  propor- 
tion of  adults  have  not  been  seri- 
ously ill  in  China.  Slightly  more 
than  half  (53%)  of  those  who  an- 
swered had  had  a  serious  disease 
(round  and  tape  worms,  dengue, 
and  trachoma,  etc.,  not  counted). 
Central  and  South  China  show  a 
larger  proportion  of  persons  who 
have  been  sick  than  does  North 
China,  just  as  (Table  74)  these 
sections  show  a  larger  proportion 
of  sicknesses. 


98       The  Health  of  Missionary  Families  in   China 


PAST   GENERAL    HEALTH 

GEOGRAPHICAL    LOCATION 


Table  78 

PAST  GENERAL  HEALTH  OF  HUSBAND  AND  WIFE 
-BY  PROVINCES. 

isi 

HUSBAND                            1 

WIFE 

S  [PROVINCE 

1^ 

No. 
Report- 
ing 

Perce 
G 

NTAGE    Rl 
ENERAL    i 

BPORTING  Past 

EALTH   As 

No. 
Report- 
ing 

Percentage  Reporting  Past 
General  Health  As 

Poor 

Fair 

Good 

Robust 

Poor 

Fair 

Good 

Robust 

Manchuria 

Shantung 

Chihli  .. 

17 
57 
80 
42 
18 
19 

"2 

1 

6 
12 

4 
19 

2 
21 

76 
51 
50 
62 
48 
47 

18 
35 
44 
19 
50 
31 

17 
58 
78 
41 
19 
19 

6 
3 
1 

29 
24 
14 
12 
32 
26 

53 
60 
54 
71 
52 
53 

12 
12 
31 

Shansi 

17 
16 

21 

North  China. - 

233 

1 

11 

55 

33 

132 

1 

20 

59 

20 

99 
17 
52 
36 
16 
44 
49 
8 
78 

1 
.... 

9 

"K 
8 

25 
7 

14 

"n 

58 
76 
62 
58 
56 
50 
59 
88 
54 

31 

24 
31 
33 
18 
43 
27 
12 
32 

100 
16 
50 
38 
17 
46 
49 
7 
79 

3 

"z 

2' 

4 

.... 

15 

25 
22 
19 
23 
17 
37 
57 
20 

59 

50 
50 
57 
59 
59 
49 
43 
54 

23 

25 

28 

Chekiang 

21 

18 

22 

10 

Kueiehow 

Szechuan 

"24" 

Cent.  China. - 

399 

2 

9 

62 

28 

402 

1 

26 

51 

19 

56 

80 

5 

"2 

9 
13 
20 

63 
61 

80 

28 
24 

57 
79 
5 

2 
4 

21 
32 
20 

60 
48 
60 

17 

Kwangtung 

Yunnan 

16 
20 

South  China. 

141 

1 

14 

68 

17 

141 

3 

24 

56 

18 

All  China 

773 

1 

11 

58 

30 

775 

3 

23 

54 

20 

Husband  &  Wife. 

1548 

2 

17 

56 

25 

.... 

—  - 

.... 

.... 

.... 

Figure  41.  Percentage  of  husbands, 
wives,  and  children  whose  past  gen- 
eral health  has  been  robust,  by  sec- 
tions.    (From  Tables  78  and  61.) 


Table  78  and  Figure  41 
show  the  past  general 
health  of  husband  and  wife 
by  provinces.  The  wives  in 
various  sections  differ  but 
little.  Husbands  are  con- 
siderably above  their  wives 
in  North  China,  and  for  all 
China  show  50%  more  who 
have  been  in  robust  health 
(30%  against  20%).  This 
in  spite  of  the  fact  that  men 
have  a  higher  morbidity 
rate  than  women.  Evident- 
ly the  general  conditions  of 
work,  and  of  child  bearing 
(normal  confinements  are 
not  counted  as  sicknesses) 
are  important  causes  of  ill 
health   for   women.      Only 


The  Health  of  Married  Adults 


99 


25%  of  the  missionaries  consider  that  their  health  has  been 
robust.  Does  this  fact  bear  any  relation  to  the  progress  of 
the  church  in  China? 

Report  made  in  1913  by  British  societies"^  showed  that 
twice  as  many  women  as  men  were  invalided  home  from  Cen- 
tral and  South  China. 


Table  79 


MISSIONARY   SOCIETIES 

PAST  GENERAL  HEALTH  OF  HUSBAND  AND  WIFE 
BY  SOCIETIES 


HUSBAND 

WIFE 

No. 
Re- 
port- 
ing 

Percentage  Reporting 

Past  General  Health 

As 

No. 
Re- 
port- 
ing 

Percentage  Reporting 

Past  General  Health 

As 

Poor 

Fair 

Good 

Robust 

Poor 

Fair 

Good 

Robust 

Y.M.  C.  A - 

London  Miss.  Soc..-. 

39 
25 

86 
31 
31 
48 
33 
72 
24 
139 
21 
31 
96 
10 
50 

5 
.... 

"z 

1 
.... 

"2 

8 
8 
8 

12 
6 
2 

22 
8 

12 

11 
9 

12 
9 

30 

12 

46 
60 
53 
55 
58 
61 
51 
56 
63 
58 
62 
63 
68 
50 
64 

41 
32 
38 
32 
35 
37 
24 
35 
25 
30 
29 
25 
23 
20 
22 

37 
24 
91 
31 
30 
47 
33 
72 
28 
143 
23 
32 
93 

50 

3 

23 
1 
3 

"\' 

"2 
4 
3 

1 

5 

'31' 
24 
16 
22 
10 
18 
25 
23 
17 
19 
26 
22 
38 

59 
42 
45 
49 
64 
57 
60 
62 
46 
57 
65 
56 
53 
55 
54 

33 
33 
23 

24 

20 

Am.  Methodist,  North 

17 
30 

American  Presbyterian,  North 

Church  Miss.  Soc -_.. 

18 
25 
17 

17 

19 

China  Inland  Mission 

German  Societies... 

20 
22 

8 

All  Societies                  ._. - 

736 
1479 

1 

1 

10 
15 

58 
57 

31 

26 

743 

2 

21 

55 

20 

All  Societies— Husband  and  Wife 



Table  79  gives  the  condition  of  health  by  societies,  those 
reporting  the  highest  percentage  with  robust  health  being 
placed  at  the  top.  The  order,  in  general,  is  similar  to  that 
found  in  the  tables  showing  mortality  of  children.  It  is  rea- 
sonable to  suppose  that  both  parents  and  children  suffer  from 
the  conditions  which  cause  ill  health. 


100     The  Health   of  Missionary  Families   in   China 


PART  III— Some  Factors  in  Prevention  of  Disease 
THE    PREVENTABLE   DISEASES 

The  largest  results  in  life-saving  come  from  concentration 
of  effort  on  the  diseases  which  are  causing  the  greatest  loss, 
and  which  are  most  easily  prevented.    The  degree  of  prevent- 
ability  is  a  most  important  factor. 

The  ratio  of  preventability  of  death  for  various  diseases  has  been 
worked  out  by  Professor  Irving  Fishers  of  Yale.  Some  of  those  of  most 
importance  in  China  are:  Prematurity,  40;  scarlet  fever,  50;  diarrhoea  and 
enteritis,  60;  dysentery,  80;  diphtheria,  70;  typhoid  fever,  85;  malaria,  80; 
smallpox,  75;  broncho-pneumonia,  50;  meningitis,  70;  tuberculosis,  75.  This 
percentage  of  the  present  number  of  deaths  could  be  prevented  if  "the  knowl- 
edge now  existing  among  well-informed  men  in  the  medical  profession  were 
actually  applied  in  a  reasonable  way  and  to  a  reasonable  extent." 

If  these  preventive  measures  could  have  been  applied  in 
China,  200  of  the  300  children  in  this  study  who  have  died  of 
these  above-named  diseases  could  have  been  saved.  Though 
many  of  these  preventive  measures  cannot  be  applied  in  China, 
much  can  be  done.  Three-fourths  of  the  deaths  of  children  in 
China  are  due  to  infectious  diseases.  This  is  the  easiest  class 
of  disease  to  prevent. 

English  statisticians'^  find  that  because  of  the  reduction 
in  death  rates  which  took  place  in  that  country  between  the 
years  1871-80  and  1910-12,  the  English  people  have  gained 
9,612,600  additional  years  of  life.  If  lives  of  missionaries 
could  be  saved  in  the  same  ratio,  probably  the  saving  in  years 
would  be  equivalent  in  the  next  three  or  four  decades  to  a 
doubling  of  the  missionary  force. 

DYSENTERY 

This  is  the  most  widespread  and  destructive  of  the  dis- 
eases attacking  missionaries  in  China.  In  this  study,  808  cases 
are  recorded,  with  84  deaths.  For  the  total  missionary  body, 
at  the  same  rate,  the  cases  would  number  over  2,000,  and  the 
deaths  over  200.  The  analysis  of  statistics  concerning  chil- 
dren shows  that  it  is  less  sensitive  than  other  infections  to 
medical  training  on  the  part  of  parents,  and  deaths  from  dys- 
entery have  not  decreased  in  recent  years  as  they  have  for 
other  infectious  diseases.  Yet  the  disease  comes  only  through 
the  victim  himself,  or  his  nurse,  putting  the  live  germs  into 
his  mouth.  Hundreds  of  thousands  of  dollars'  worth  of  time 
and  lives  could  be  saved  in  a  few  years  if  missionaries  knew 


Some  Factors  in  Prevention   of  Disease 


101 


and  applied  the  proper  preventive  measures.  These  measures 
imply  the  possession  of  kitchens  which  can  be  kept  clean,  and 
the  means  for  properly  sterilizing  food  and  drink. 

TYPHOID   FEVER 

If  the  death  rate  from  typhoid  for  adults  were  known,  it 
would  be  a  much  larger  item  than  it  is  for  children,  since  adults 
are  more  susceptible.  Unlike  dysentery,  we  have  in  preventive 
inoculation  an  invaluable  weapon  for  fighting  the  disease. 

The  morbidity  from  typhoid  in  the  missionary  army  in 
China  and  in  the  United  States-^  army  is  compared  in  Table  80. 


Table  80 


SICKNESS  FROM  TYPHOID  FEVER  AMONG  MARRIED  MISSION- 
ARIES AND  UNITED  STATES  SOLDIERS 


Cases  op  Typhoid  per  1,000  Years 
OP  Service 


U.  S.  Anny,  1900-1908  (before  compulsory  inoculation) 
U.  S.  Army,  1912-1918  (after  compulsory  inoculation).. 
Married  Missionaries  (before  1919) _.- 


5.65 

.23 

7.69 


TYPHOID        FEVER. 

CASES       PER       lOOO     VEAft.3     oP       5ERV/CE 

^                                                      4                                                    15 

n 

ADULT      MI2JIONARIL£ 

1 

'880-  19l« 

U.S.   A»MY        (900-  I9O0 
BEfORE    COMPUtSOHY 
VACCIHAT/ON 

■ 

(i.S.  ARMr     ■   1913  ■  1918 
AFTCI'.     COMPUiaORy 
VACCIWATIOM 

Figure  42.     Sickness  from  typhoid  fever  among  married  missionaries 
and  United  States  soldiers.      (Illustrating  Table  80.) 

Figure  42  shows  how  the  rate  has  been  lowered  in  the 
United  States  araiy  following  the  compulsory  use  of  typhoid 
— paratyphoid  inoculations. 

If  typhoid  inoculation,  together  with  reasonable  care  of 
food  and  drink,  were  used  by  all  missionaries,  the  morbidity 
rate  from  typhoid  could  be  reduced  to  the  point  reached  by 
the  army.  In  this  event,  using  the  values  worked  out  by  G. 
C.  Whipple,^''  that  each  death  from  typhoid  represents  a  loss 
of  $6,000  {i.e.,  $4,634  for  each  person  dying  and  $1,366  through 
disability  for  those  cases  that  did  not  die),  and  assuming  that 
during  the  next  decade  on  the  field  the  missionary  force  in 
China  will  average  7,500  adults,  the  amount  of  money  saved 
to  the  societies  in  that  time  would  be  $336,000.  If  we  consider 
the  trained  missionary  worker  of  several  times '  greater  value 
than  the  average  person  of  the  United  States  is  to  his  com- 
munity, this  amount  should  be  multiplied  several  times. 


102     The  Health   of  Missionary  Families  in   China 


pooooo                               2oo  ooo                              3oo  ooo 

SSTIMATCC       SAVINO 

WITH      UNIVERSAL 
JNOCULATION 

COST    OF     VACCINE 

BH 

B 

COST    OF    VACCINE, 
IN       MISSION 
UABORATOR-V 

Figure  43.     Amount  of  money  which  would  be  saved  in  ten  years 

on  the  field  with  typhoid  fever  rate  reduced  to  that  of 

United   States  Army. 


The  above  figure  is  arrived  at  in  the  following  way:  127  cases  of  typhoid 
are  reported  as  occurring  during  the  17,600  years  spent  in  China,  or  7.69 
cases  per  1,000  years.  If  the  rate  were  reduced  to  .23,  7.46  cases  per  1,000 
years  would  be  saved.  In  75,000  years  this  would  amount  to  560  cases. 
Among  British  missionaries2T  in  all  fields  it  was  found  that  29%  of  the  cases 
of  typhoid  resulted  fatally.  Suppose,  however,  that  only  10%  die,  5G  lives 
would  be  saved.  At  $6,000  this  would  amount  to  $336,000.  In  this  tabulation 
the  estimated  number  of  adults  on  the  field  is  less  than  the  number  used  in 
a  previous  article.25 

The  cost  of  vaccine  would  be  but  a  small  fraction  of  the 
amount  saved,  and  probably  90%  of  this  in  turn  could  be 
saved  if  vaccine  were  produced  in  the  laboratories  of  a  mis- 
sionary medical  school  and  sent  in  bulk  to  all  mission  stations. 

Wide-awake  missionaries  and  mission  boards  recognize 
the  value  of  this  method  of  insurance  against  typhoid.  Yet  a 
census  of  newly  arrived  missionaries  in  the  Peking  Union 
Language  School  in  1920  showed  that  20%  had  been  sent  to 
China  without  this  protection. 

A  word  of  warning  concerning  inoculation  is  needed: 
"The  triple  typhoid  inoculation  confers  a  high  degree  of  protection 
against  typhoid  and  paratyphoid  fevers,  but  it  does  not  give  absolute  protec- 
tion against  massive  infection  with  the  causitive  organisms  ...  it  does  not 
warrant  neglect  of  the  other  well-known  sanitary  precautions  against  the 
disease."     (U.  S.  War  Department— Regulations  No.  28.     March  11,  1919). 3i 

Among  adults,  127  cases  of  typhoid  fever  developed  in 
China,  and  37  cases  outside;  77%  of  the  cases,  therefore,  oc- 
curred in  China.  The  persons  have  spent  an  average  of  11 
years  in  China,  which  is  not  more  than  a  third  of  their  life- 
time. The  chances  of  the  missionary  getting  typhoid  has  been, 
therefore,  about  12  times  as  great  in  China  as  at  home. 

SMALLPOX 

Most  of  the  cases  of  typhoid  fever  occurred  before 
typhoid  inoculation  had  been  introduced.  All  the  cases  of 
smallpox,  on  the  other  hand,  occurred  more  than  a  hundred 
years  after  Jenner  demonstrated  to  the  world  that,  except 


Some  Factors  in  Prevention  of  Disease 


103 


in  rare  instances,  vaccination  will  protect  from  smallpox.  In 
this  study,  111  cases  of  smallpox,  with  28  deaths,  are  reported 
among  adults  and  children.  For  the  whole  missionary  body  in 
China  this  would  mean  a  total  of  about  260  cases,  with  55 
deaths. 


Table  81  MORTALITY  FROM  SMALLPOX  AMONG  MISSIONARY  FAMILIES 

(ADULTS  AND  CHILDREN)  AND  AMONG  GENERAL 
POPULATION  IN  ENGLAND  AND  THE  UNITED  STATES 


Number  of  Deaths  prom  Smallpox 


Per  100,000  inhabitants  in  England  and  Wales,  2'  1893-1902 
England  and  Wales,  1903-1917 

United  States  Registration  Area,  1904-1908" 

Per  100,000  years  Spent  in  Claina  by  Missionaries 


2.1 
.29 
.72 
68.5 


........ 

"" 

THi 

110 

>    l,v„o(fOR. 
|20 

,JO 

^ 

rtr. 

too  000 
|4o 

VE*R3 

IN     CHI 
ISO 

KA) 

,60 

HIiJIOWARY     CHILD- 

REK    AUD    PARENTS 

1880    1918 

1                                     1                                     1                                     1                                      '                                     '                                    1 

■ 

1 

1 

ma 

• 

QEHERAL    POfULATlOK 

reos.    I»i7 

UmTED      STATES 
t5>OA      tOOO 

Figure  44.   Mortality  from  smallpox  in  missionary  families  and  in  England 
and  the  United  States.     (Illustrating  Table  81.) 


Table  81  and  Figure  44  show  the  relative  mortality  among 
missionaries'  families  in  China  and  the  general  population  of 
the  United  States  and  England  for  closely  corresponding 
periods. 

It  has  been  pointed  out,  already,  that  most  of  the  loss 
from  smallpox  has  been  borne  by  three  groups  of  societies. 

Among  adults,  28  cases  of  smallpox  are  reported  from 
China  and  3  from  outside;  90%,  therefore,  were  contracted  in 
China — during  only  one-third  the  life-time.  The  likelihood  of 
the  missionary  getting  smallpox  has  been  about  30  times  as 
great  in  China  as  at  home. 

One  missionary  writes :  *'0f  26  missionaries  of  one  board 
who  have  come  to  this  district,  12  have  been  attacked  by 
smallpox."  The  high  incidence  of  smallpox  immediately 
raises  an  important  question.  How  many  of  these  cases  were 
contracted  in  spite  of  the  person  having  been  vaccinated? 


104     The  Health   of  Missionary  Families  in   China 

To  determine  this  point,  the  writer  sent  a  question  blank 
to  50  families,  which  had  reported  cases  of  smallpox.  In  an- 
swer, 30  families  reported  51  cases  of  smallpox,  37  of  which 
were  not  fatal  and  14  fatal.  The  answers  are  summarized 
in  Table  82 : 


Table  82 


CASES  OF  SMALLPOX,  WITH  REFERENCE  TO  PREVIOUS 
VACCINATIONS 


Number  of 

Successful 

Vaccinations 

ATTACK  FATAL 

ATTACK  NOT  FATAL 

Age  at  Attack 

Age  at  Attack 

0-1 
Year 

1-4 

Years 

5-19 
Years 

20  Plus 
Years 

0-1 
Year 

1-4 
Years 

5-19 
Years 

20  Plus 
Years 

Not 
Stated 

None. .   

8 

1 

1 



5 

2 
1 

11 
3 

2 
2 

3 
6 
3 

1 

3 

One 

Two _ 

Three 



Total 

9 

1 

5 

3 

14 

4 

13 

3 

Seventeen  of  the  persons  had  been  vaccinated,  35  had  not 
been.  In  12  of  the  14  fatal  cases  vaccination  had  not  been 
attempted.  One  other  (a  baby  of  eight  months)  had  had  an 
unsuccessful  vaccination  three  months  before.  Out  of  the  14 
cases,  there  is  record  of  only  one  case  dying  from  smallpox 
after  being  successfully  vaccinated.  In  this  case  (a  seven- 
months-old  baby)  the  vaccination  had  been  done  three  weeks 
previously.  Of  these  14  fatal  cass,  eight  were  among,  infants, 
and  five  among  adults. 

Of  the  37  cases  which  did  not  end  in  death,  21  had  not 
been  successfully  vaccinated.  Of  the  21,  in  seven  cases  vacci- 
nation had  been  attempted,  but  had  not  ''taken."  Sixteen 
cases  had  had  successful  "takes."  Of  these  twelve  had  had 
one  "take;"  three,  two  "takes;"  and  one  had  had  three 
"takes." 

In  these  cases  it  is  important  to  know  how  long  a  time 
had  elapsed  between  vaccination  and  contraction  of  the  dis- 
ease. In  those  who  had  had  one  "take,"  the  interval  was  in 
one  case  only  a  few  days  (a  child  exposed  when  the  mother 
developed  smallpox).  In  three  cases  the  interval  was  a  year; 
in  one  case,  four  years ;  three  cases,  between  five  and  fifteen 
years,  and  in  four  cases,  more  than  fifteen  years. 

Of  the  three  cases  which  had  had  two  "takes,"  the  inter- 
val in  one  case  was  one  year,  and  in  two  cases,  ten  to  fourteen 
years.  Only  one  case  developed  after  three  "takes."  Here 
the  last  "take"  was  but  a  few  days  before.  (Vaccination 
done  just  before  the  disease  breaks  out  will  not  protect.) 


Some  Factors  in  Prevention  of  Disease  105 

Eight  cases  of  smallpox  occurred  less  than  five  years 
after  vaccination.  Two  of  these  were  only  a  few  days  after, 
so  that  immunity  had  not  had  time  to  become  established. 

One  would  expect  the  six  other  cases  to  be  protected. 
Three  of  these  cases  were  in  one  family.  Vaccination  had  been 
done  fifteen  months  before,  and  all  three  had  large  scars  to 
show  for  it.  Of  17  cases,  then,  which  followed  successful  vac- 
cination, six  were  within  a  period  in  which  the  individual 
should  have  been  immune. 

The  information  collected,  though  meagre,  serves  to  em- 
phasize the  importance  of  vaccination.  Every  death,  with  the 
exception  of  one,  came  in  unvaccinated  persons.  The  non- 
fatal cases  which  occurred  in  vaccinated  individuals  would 
indicate  that  vaccinations  should  be  repeated  at  shorter  inter- 
vals in  China  than  in  countries  where  smallpox  has  been 
almost  eradicated. 

Several  of  the  reports  blamed  the  vaccine  used  for  unto- 
ward results — eczema,  epilepsy,  even  smallpox  itself.  Though 
the  vaccine  was  not  to  blame,  arrangements  should  be  made 
so  that  the  missionary  body  may  be  sure  of  a  pure,  fresh 
supply. 

Eight  cases  developed  smallpox  after  failure  to  get  a 
"take."  In  one  case — a  baby — the  attempt  had  been  made 
three  times,  the  last  one  but  three  months  before  the  attack. 
This  points  to  the  need  of  repeated  attempts  at  vaccination. 
The  writer  knows  of  a  successful  vaccination  of  a  baby  after 
fourteen  unsuccessful  attempts. 

It  is  of  interest  to  look  at  larger  figures  on  this  subject  collected  in  the 
United  States.  Among  134,669  vaccinated  persons  exposed  to  smallpox,  619, 
or  .46%,  contracted  the  disease,  of  whom  13,  or  4.2%,  died.  Among  147,941 
unvaccinated  and  exposed  persons,  on  the  other  hand,  4,056,  or  2.7%,  became 
sick,  of  whom  282,  or  12.6%,  died.  That  is,  the  sickness  rate  among  unvac- 
cinated is  six  times  what  it  is  in  the  vaccinated,  and  the  death  rate  three 
times  as  great,  or  the  chances  of  dying  of  smallpox  are  18  in  the  unvacci- 
nated to  1  in  the  vaccinated. •''^  in  another  investigation  in  New  York 
City"-!  of  534  vaccinated  persons  who  were  exposed  to  smallpox,  none  became 
sick,  while  of  7,567  unvaccinated  persons,  161,  or  2%,  contracted  smallpox. 

These  three  diseases  have  been  mentioned  because  they 
are  most  destructive  (dysentery),  or  have  a  specific  means  of 
prevention  (smallpox  and  typhoid).  The  evidence  concerning 
other  diseases  (e.g.,  malaria,  scarlet  fever,  diphtheria)  might 
be  analyzed  with  profit. 

CAUSES    OF   INFECTION 

Correspondents  were  asked  to  state,  whenever  possible, 
the  cause  of  the  sicknesses.    A  great  variety  of  factors  were 


106     The  Health  of  Missionary  Families  in   China 

named.  Lack  of  medical  attention  was  mentioned  37  times, 
usually  in  cases  which  resulted  fatally.  Inexperienced  med- 
ical attention  was  blamed  five  times.  Contaminated  food, 
milk,  water,  unscreened  houses,  ignorant  servants,  boat  travel 
(9  cases  of  dysentery,  with  2  deaths,  among  18  passengers  on 
one  trip  of  a  Yangtse  river  boat),  privation,  poor  houses,  flies, 
over-medication,  epidemics  among  Chinese,  etc.,  were  named 
from  one  to  many  times. 

METHODS    OF   DISEASE    PREVENTION 

One  hundred  and  eighty-six  of  those  who  filled  out  the 
questionnaire  (about  14%)  gave  advice  on  the  subject  of  main- 
tenance of  health.  The  various  points  named  are  listed  in  the 
following  table.  The  figures  refer  to  the  number  of  corre- 
spondents who  mentioned  the  subject. 

Table  83  ADVICE  CONCERNING  HEALTH  GIVEN  BY 

MISSIONARIES 

Relating  to  Mission  Boards: 

Institute  comprehensive  health  survey 1 

Provide  thorough  physical  examination  of  candidates 1 

Provide  medical  examiners  conversant  with  conditions  on  the  field.  1 

Provide  medical   instruction   to  candidates 1 

Provide  information  concerning  conditions  on  the  field 1 

Provide  more  medical  attention  on  the  field 1 

Provide  professional  and  nursing  care  for  women  at  childbirth. ...  2 

Have  a  rule  that  women  be  on  the  field  for  a  year  before  marriage  1 

Increase  the  salaries 2 

Have  a  shorter  time  between  furloughs 2 

Build  better  residences   1 

Provide  houses  at  summer  resorts 1 

Supervise  the  schools  for  children 1 

Relating  to  Stations: 

Display  real  Christian  spirit 1 

In  assignments,  consider  compatibility  of  dispositions 1 

Each  family  should  board  separately 1 

Relating  to  Housing: 

Arrange  in  large  compound 2 

Have  modern-style  houses   6 

Have  Chinese-style  houses 1 

Sanitary   plumbing,   etc 4 

Proper  screening   26 

At  a  distance  from  the  street 3 

Drain  neighboring  pools  2 

Have  self-closing  servants'  closet 1 

Have  separate  kitchen  for  servants 1 

Relating  to  Missionary  Doctors  and  Nurses: 

Give  more  careful  attention  to  foreign  patients 3 

Advise  early  smallpox  vaccination 4 

Warn  community  of  sickness 1 

Give  better  prenatal  care  to  missionary  wives 1 

Examine  wives  after  illness 1 

Maintain    stricter    quarantine 1 

Give  furlough  for  sickness  before  death  is  imminent 1 


Some  Factors  in  Prevention  of  Disease  107 

Relating  to  Yacations  and  Travel: 

Go  to  summer  resort 22 

Don't  go  to  summer  resort  2 

Avoid    summer    travel 1 

Take  extra  care  in  traveling 2 

Don't  travel  third  class 1 

Be  careful  of  food  on  river  steamers 2 

Relating  to  the  Family — General  Points: 

Study  elements  of  medicine  before  coming 8 

Don't  worry    1 

Get  to  feeling  at  home 2 

Maintain  a  confident  attitude 2 

Acquire  common  sense    1 

Keep  regular  hours   1 

Daily  exercise  and  recreation 13 

Daily  bath   1 

Go  to  bed  with  clean  mouth 1 

Expectorate  after  bad  smells 1 

Don't  worry  about  germs 3 

In  sickness,  trust  the  Lord 2 

Live  as  the  Chinese  do 1 

A  little  private  income  important 1 

Rest  after  tiffin   1 

Take  life  easy  at  first 1 

Listen  to  advice  of  older  missionaries 1 

Older  missionaries   should  advise 1 

Have  a  family  game  before  bed-time 1 

Have  proper  bowel  habits J 

Have  comfortable  beds   1 

Carry  mosquito  essence 1 

Control   flies    2 

Have  regular   medical  examination 1 

Take  typhoid  and  paratyphoid  vaccination 2 

In  cold  weather  wear  nightcaps 1 

Relating  to  Parents: 

Avoid  children  too  often 4 

Have  a  small  family 1 

Avoid  early  child-bearing  on  the  field 3 

Learn  duty  of  refusing  to  do  good  at  family  expense 1 

Relating  to  the  Mother: 

No  language  study  during  pregnancy 1 

Learn  the  language   1 

Get  "Holt"  1 

Exercise  extra  care  during  pregnancy 8 

Avoid  cart  travel  when  pregnant 3 

Stay  in  bed  a  month  following  childbirth 1 

Give  less  time  to  mission  work  and  more  to  children 1 

Relating  to  Housekeeping: 

Learn  how  to  cook 1 

Be  a  good  housekeeper 4 

Personally  supervise  the  kitchen 4 

Provide  more  proteids  in  diet 2 

Provide    more    fats 1 

Eat  fresh  bread   ( to  avoid  sprue) 1 

Scald  and  then  bake  bread  bought  on  the  street 1 

Scald  fruit  1 

Use  only  boiled  water 24 

Use  only  boiled  milk 12 

Use  only  cooked  vegetables 4 


108     The  Health  of  Missionary  Families  in   China 

Relating  to  the  Care  of  Children: 

Personal  supervision  of  children  by  the  mother 2ti 

Personally  prepare  babies'  food 5 

Personally  feed  children  5 

Use  care  in  preparing  food 1 

Serve  plain  food   5 

Cow's  milk  important 3 

Keep  your  own  cow   1 

Use  goat's  milk   1 

See  that  the  milk  is  not  watered 3 

Use  tinned  milk  1 

Use  wet  nurse  if  mother's  milk  fails 2 

Let  children  eat  only  at  table 4 

Don't  allow  them  to  eat  servants'  food 1 

Don't  allow  them  to  eat  Chinese  food 3 

Don't  allow  them  to  eat  Chinese  candy 1 

Serve  only  cooked  foods 1 

Serve  plenty  of  fruits 2 

Send  children  home  between     5  and  10  years 4 

Send  children  home  between  10  and  15  years 2 

Send  children  home  between  15  and  20  years 2 

Keep  children's  fingers  out  of  the  mouth 2 

Boil  bath  water   1 

Have  daily  mouth  gargling  1 

Relating  to  Children's  Bleep  and  Play: 

Follow  usual  normal  life 4 

Provide  exercise    2 

Lead  outdoor  life   •• 

Don't  let  the  baby  creep  on  the  floor 2 

Don't  allow  children  to  play  in  pools 1 

Guard  against  loneliness    (in  isolated  stations) 1 

Put  to  bed  by  mother  (to  prevent  bad  habits) 1 

Put  to  bed  early   1 

Provide  mosquito  nettings   4 

Open  windows    3 

Sleep  outdoors    ? 

Use  mosquito   lamp    i 

Keep  inside  after  sundown  in  winter  1 

Relating  to  Clothing: 

Dress  warmly  in  winter    2 

Wear  cholera  belt  3 

Protect  from   sun    5 

Use  sun  hats    4 

Provide  stout  shoes   1 

Don't  allow  the  children  to  go  barefooted  on  ground 1 

Relating  to  Medical  Attention: 

"Watch    stools    1 

Demand  daily  bowel  movement  2 

Provide  glasses  if  necessary 2 

Give  periodic  quinine    2 

Don't  give  too  much  quinine  1 

Give  periodic  santonine  1 

Have  semi-annual  examination  for  worm  eggs 1 

Use  prompt  dieting  on  diarrhoea 1 

Have  circumcised    1 

Early  smallpox  vaccination  1 

Relating  to  Relations  with  Chinese: 

Keep  from  Chinese  visitors 1 

Keep  from  Chinese  children 2 

Allow  to  play  with  Chinese  children 1 


Some  Factors  in  Prevention  of  Disease  109 

Servants — 

The  fewer  the  safer  1 

Instruct  servants  6 

Watch  servants    2 

Keep  children  from  servants  ;; 

Keep  children  from  other  people's  servants 1 

Have  servants  examined  by  doctor 1 

Watch  for  tuberculosis 4 

Watch  for  dysentery  ] 

Watch  for  malaria 1 

Watch  for  syphilis 1 

Watch  for  trachoma 2 

Relating  to  Amah: 

Have  none  3 

Select  with  care 1 

Don't  change  often  ] 

Require  to  bathe  regularly   1 

Provide  with  clean  garments 1 

Watch  for  teaching  immoral  practices  1 

Relating  to  Schools: 

They  are  not  properly  heated -.  2 

Exercise  and  play  neglected   ] 

Children  from  south  should  go  north 1 

Health  in  China  and  at  Home: 
Chance  for  health  in  China — 

Better  than  in  homeland   3 

As  good  as  in  homeland  (if  certain  precautions  are  taken) 29 

Worse  than  in  homeland 18 

Many  of  the  collaborators  in  this  study  wrote  feelingly  on  certain  phases 
of  this  subject.  There  is  not  space  to  reproduce  these  letters,  but  some  of  the 
more  striking  sentences  are  set  down. 

"Health  of  children  not  so  good  in  China?    Rubbish." 
"Some   missionaries  would   be   happier   if  they   knew   more   about   the 
interior  of  China  and  less  about  the  interior  of  themselves." 

"  'Trust  in  the  Lord  and  do  good — so  shalt  thou  dwell  in  the  land.'  " 
"  'Take  cheerfully  the  spoiling  of  your  goods.'  " 
"Don't  let  your  people  send  you  funeral  orations  by  every  mail." 
"The   excessive   care   necessary   makes    the    children    selfish    and    self- 
absorbed." 

"During  the  nursing  months  I  live  more  nearly  the  life  expected  of  a 
good  cow." 

"A  properly  trained,  trustworthy,  Christian  amah  is  better  than  a 
mother." 

"I  (reared  in  China)  know  that  some  missionary  children  are  allowed 
to  learn  vileness  from  bad  servants.  No  mother  ought  to  be  so  absorbed  in 
the  souls  of  the  Chinese  that  she  lets  the  devil  get  the  bodies  of  her  children." 

"Health  is  largely  up  to  the  housekeeper." 

"It  ought  to  be  language  first  then  babies,  or  babies  first  then  language, 
but  certainly  not  both  at  the  same  time." 

"Don't  let  young  missionaries  presume  on  God's  almightiness  to  nullify 
rashness." 

"The  worm  (round)  that  dieth  not." 

"Our  doctors  pay  no  attention  to  prenatal  examinations." 

"At  home,  the  people  who  have  the  best  doctors  money  can  engage  do 

not  get  the  good  attention  I  have  had  on  the  field,  because  these  best  doctors 

are  so  busy." 


110     The  Health   of  Missionary  Families  in   China 

"Microscopes  are  time  consumers,  but  life  preservers." 

"Have  a  physical  examination  once  a  year  by  a  physician  that  will  do 
a  good  job  of  it  and  take  some  time  to  it." 

"Get  a  'fool-proof  closet  stool  cover;  keep  the  place  whitewashed  and 
clean-looking,  so  they  (the  servants)  will  be  proud  of  it.  Put  a  self-closing 
screen  door  on  it  in  summer  and  hang  a  fly-swatter  in  it  and  encourage 
its  use." 

"In  one  sample  of  cow's  milk  there  was  75%  of  water." 

"Wanted,  a  'Holt,'  adapted  for  feeding  in  China." 

"Put  play  Into  your  schedule  as  religiously  as  you  put  work  or  Bible 
study." 

(From  a  physician) :  "I  would  keep  every  pregnant  and  every  nursing 
woman  from  language  study.  No  one  will  believe  in  the  necessity  of  such 
regulations  unless  she  first  transgresses  them,  and  then  the  fat  is  in  the  fire." 

"One  cannot  expect  the  children  of  mothers  to  be  well  when  the  mothers 
.  .  .  permit  the  ignorant  and  dirty  Chinese  to  feed  and  care  for  the  chil- 
dren's wants." 

(From  a  physician) :  "When  children  do  get  sick  they  get  much 
Inferior  care,  on  the  whole,  than  they  would  get  at  home.  Everybody  is  so 
busy  making  statistics  that  foreign  patients  do  not  count.  All  appear  to  be 
affected  with  the  Bacillo  coccus  statistinitis.  Quantity  instead  of  quality  is 
the  watchword." 

THE    RESPONSIBLE    AGENCIES 

Considering  all  the  difficult  circumstances  of  the  past, 
missionaries  and  mission  boards  have  doubtless  done  the  best 
possible  for  the  health  of  the  workers.  Mortality  rates  are 
doubtless  pigmy  sized  in  comparison  with  the  huge  physical 
difiBculties  faced.  However,  in  the  light  of  important  new 
medical  knowledge,  in  the  light  of  the  present  tremendous 
urgency  for  the  missionary  program,  in  the  light  of  freshly 
opened  reservoirs  of  funds,  in  the  light  of  growing  unity 
among  Christian  forces, — the  health  record  for  the  past  will 
not  do  for  the  future.  The  problem  of  the  health  of  the  work- 
ers needs  to  be  handled  in  a  new  and  bigger  way. 

The  purpose  of  this  study  is  to  set  forth  the  facts  con- 
cerning the  health  of  a  certain  portion  of  the  missionary  force 
in  China.  It  does  not  aim  to  present  a  detailed  health  pro- 
gram.   That  can  be  done  only  by  the  mission  boards. 

This  study  would  be  incomplete,  however,  if  the  agencies 
concerned  in  the  safeguarding  of  health  were  not  indicated. 

1.  The  Individual  Missionary.  Most  of  the  161  items  of 
Table  83  are  concerned  with  the  precautions  which  the  indi- 
vidual should  follow.  In  a  country  where  one  must  be  his  own 
board  of  health  such  individual  measures  are  most  essential. 

2.  Missionary  Doctors.  Doctors  are  supposed  to  bear  the 
same  relation  to  the  missionary  body  that  the  medical  corps 
of  the  army  bears  to  the  force  in  the  field,  but  they  cannot 
fully  live  up  to  that  relationship  without  either  large  rein- 
forcements, or  a  decrease  in  their  work  for  the  Chinese. 


Some  Factors  in  Prevention  of  Disease  111 

3.  Groups  on  the  Field.  United  efforts  by  mission  sta- 
tions, the  China  Medical  Missionary  Association,  union  lan- 
guage schools,  and  other  union  organizations  can  assist 
greatly  in  making  health  measures  effective.  An  encouraging 
feature  is  the  coming  of  the  China  Medical  Board.  With  the 
opening  of  the  Peking  Union  Medical  College  hospital,  mis- 
sionaries in  China  have  at  their  disposal  the  advice  of  special- 
ists who  are  supplied  with  all  the  up-to-date  equipment  for 
the  diagnosis  and  treatment  of  disease, 

4.  The  Individual  Missionary  Boards.  In  such  matters 
as  the  securing  and  dissemination  of  accurate  information 
concerning  sickness  on  the  field,  the  best  methods  of  disease 
prevention,  in  the  matter  of  salaries,  housing,  period  of  serv- 
ice, schools  for  children,  etc.,  the  responsibility  rests  not  with 
the  missionaries,  but  with  the  boards  for  which  they  work. 

The  China  Medical  Missionary  Association  at  its  last  con- 
ference held  at  Peking,  in  February,  1920,  after  considering 
some  of  the  facts  of  this  study,  unanimously  passed  the  follow- 
ing resolutions : 

Whereas,  the  health  of  the  individual  missionary  and  his  family  is 
essential  to  the  success  of  the  missionary  enterprise,  and, 

Whereas,  the  war  has  demonstrated  the  possibility  of  greatly  reducing 
disease  among  the  forces  in  the  field  through  the  use  of  modern  methods  of 
prevention  and  cure;  and. 

Whereas,  preventable  sickness  and  death  constitutes  a  continuing  drain 
on  the  Christian  forces  in  China;  therefore, 

Resolved,  that  the  China  Medical  Missionary  Association  should  and 
hereby  does  call  the  attention  of  the  missionary  boards  doing  work  in  China 
to  the  need  of  an  energetic,  comprehensive,  co-operative  program,  looking 
toward  the  physical  well-being  of  the  workers  in  the  field.  Among  other 
items,  such  a  program  should  include: 

"First,  the  tabulation  by  the  boards  of  their  health  statistics  for  the 
past,  and  where  the  records  are  inadequate,  the  installation  of  a  system 
of  vital  bookkeeping  by  means  of  which  they  and  the  doctors  on  the  field  may 
be  in  possession  of  the  basic  facts  necessary  for  intelligent  action. 

"Second,  a  thorough  physical  examination  of  candidates,  with  a  greater 
degree  of  co-operation  between  examining  physicians  at  home  and  physicians 
on  the  field. 

"Third,  the  more  complete  instruction  of  missionaries  in  the  best  means 
of  guarding  against  disease  in  the  section  of  the  country  in  which  they  are 
to  work. 

"Fourth,  the  securing  for  the  missionaries  of  all  the  up-to-date  means 
for  the  prevention  of  disease,  such  as  yearly  physical  examinations,  regular 
vaccination  against  typhoid,  paratyphoid,  and  smallpox,  proper  housing, 
screening,  etc." 

The  China  Medical  Missionary  Association  especially  offers  its  support 
In  the  planning  and  in  the  execution  of  any  such  forward  looking  program, 
and  it  hereby  directs  its  executive  committee  to  lay  this  matter  before  the 
missionary  boards  doing  work  in  China,  and  to  act  with  the  boards  in  any 
measures  which  they  may  adopt. 


112     The  Health  of  Missionary  Families  in   China 

It  should  be  pointed  out  that  some  of  the  boards  have 
had  already  in  force  policies  which  cover  most  or  all  of  the 
points  enumerated  in  the  foregoing  resolutions. 

As  an  example,  the  plans  of  the  Methodist  Episcopal,  North,  board  may  be 
mentioned.  In  this  board  there  is  a  medical  department  headed  by  a  returned 
medical  missionary,  Dr.  J.  G.  Vaughan.  The  health  policy  of  the  board 
includes,  besides  other  lesser  items,  the  following:  A  thorough  physical  exam- 
ination of  candidates  made  by  certain,  well-trained,  well-paid  examiners  in 
various  centers  in  the  country;  examination  blanks  made  in  quadruplicate 
and  a  copy  sent  to  the  physician  on  the  field;  a  health  efficiency  study  based 
on  health  reports  received  trimesterly  from  each  missionary  on  the  field;  a 
card  index  with  complete  health  record  of  each  missionary;  the  issuance  of 
Life  Extension  Institute  Bulletins;  typhoid  inoculations  every  two  years; 
and  supervision  of  activities  of  missionaries  on  furlough  with  special  refer- 
ence to  the  requirements  of  health.     This  policy  was  adopted  two  years  ago. 

The  policy  also  recognizes  the  importance  of  co-operation  between 
boards  in  such  common  problems  as  proper  examinations,  health  surveys, 
etc.,  but  unfortunately  little  in  this  line  has  been  accomplished.  The  writer 
understands  that  in  this  respect  British  societies  are  considerably  ahead  of 
American  societies. 

The  Young  Men's  and  Women's  Christian  Associations,  though  they 
have  no  practicing  physicians  on  the  field,  are  particularly  careful  concerning 
examinations,  requiring  yearly  physical  examinations  on  the  field  and  such 
a  thorough  overhauling  as  is  given  at  the  Mayo  Clinic  when  on  furlough. 

Certain  other  boards  take  a  lively  interest  in  the  health  of 
their  workers.  Yet,  considering  China  as  a  whole,  as  this  study 
does,  it  is  evident  that  many  of  the  boards  are  far  too 
lax.  In  order  to  gain  an  idea  of  the  thoroughness  of  the  atten- 
tion paid  to  the  physical  life  of  the  successful  candidate,  a 
brief  questionnaire  was  circulated  in  January,  1920,  among 
the  students  of  the  North  China  Union  Language  School. 

Sixty-eight  adults,  all  but  two  of  whom  had  come  to  China 
within  a  year,  filled  out  the  question  blank.  Fifteen  mission 
boards  were  represented.  Of  these  68,  30%  had  been  exam- 
ined by  doctors  of  their  own  selection,  23%  had  been  given 
no  advice  concerning  the  maintenance  of  health  on  the  field, 
20%  had  not  been  inoculated  against  typhoid  fever,  6%  had 
not  been  vaccinated  (none  of  these  were  protected  by  recent 
vaccination),  9%  had  not  had  their  urine  examined.  All  but 
one  had  had  a  chest  examination.  Most  of  the  neglected  cases 
belonged  to  a  certain  few  of  the  boards. 

5.  Co-operation  Behveen  Boards.  There  are  certain 
measures  which  individual  boards  cannot  put  into  operation, 
at  least  not  without  wasteful  duplication  of  effort  and  expense. 
The  most  important  word  in  the  C.  M.  M.  A.  resolutions  is 
"co-operative."  Not  only  at  home  (in  ways  suggested  in 
the  above-mentioned  policy),  but  also  on  the  field,  more 
active  co-operation  is  possible.    For  example,  this  study  shows 


Some  Factors  in  Prevention  of  Disease  113 

the  overshadowing  importance,  even  in  the  families  of  the 
medically  trained,  of  the  intestinal  infections,  dysentery, 
diarrhoea,  cholera,  etc.  For  the  prevention  of  these  diseases 
better  sanitation  is  essential.  But  the  sanitation  of  mission 
stations  and  Chijiese  cities  cannot  be  directed  from  New 
York,  London,  Stockliolm,  and  Copenhagen.  Missionary  doc- 
tors have  neither  the  time  nor  the  special  training  for  this. 

There  is  needed  a  staff  of  health  officers  and  sanitary 
engineers  on  the  field,  working  under  some  union  body  such 
as  the  Joint  Council  on  Public  Health  or  the  China  Continu- 
ation Committee,  Such  a  staff  could  compile  vital  statis- 
tics for  the  whole  missionary  body,  advise  stations  and  sum- 
mer resorts  concerning  sanitation,  provide  vaccines,  conduct 
researches  into  the  problems  of  health  and  promote  public 
health  measures  among  the  Chinese  in  the  cities  in  which  mis- 
sionaries reside. 

As  an  instance  of  a  minor  problem  in  which  missionaries  can  be  helped, 
the  following  example  is  mentioned: 

At  the  Peking  Union  Medical  College,  under  the  leadership  of  Dr.  J.  H. 
Korns,  400  servants  in  the  families  of  missionaries  and  other  foreigners  have 
been  examined  for  chronic  communicable  diseases.  Eleven  per  cent  were 
found  to  have  a  positive  blood  test  for  syphilis,  11%  had  trachoma,  48% 
round  worms,  1.8%  hook  worms,  1.7%  were  meningitis  carriers,  and  1.2% 
diphtheria  carriers.  Through  treatment  of  servants  who  are  diseased,  through 
lantern  lectures  on  home  sanitation,  as  well  as  through  the  emphasis  placed 
on  good  health,  it  is  felt  that  the  danger  of  infection  from  household  servants 
in  Peking  is  considerably  lessened.  For  those  employers  whose  servants 
have  been  found  free  of  infectious  disease,  one  cause  of  worry  is  removed. 

Because  of  the  necessity  of  using  boiled  vegetables  and 
milk,  and  expensive  butter,  the  supplying  of  the  growing  child 
with  a  properly  balanced  diet,  containing  necessary  food  ele- 
ments, is  a  problem.  (121  cases  of  difficult  feeding  and  mal- 
nutrition and  13  cases  of  rickets  were  reported,  but  no  case 
of  scurvy.)  Wilson,"*"  and  Adolph  and  Kiang"  are  studying 
the  nutritive  value  of  Chinese  foods.  Taylor"*^  has  presented 
work  on  the  feeding  of  the  foreign  baby.  Mills^®  has  pointed 
out  the  value  of  chloride  of  lime  for  the  sterilization  of  water 
in  country  traveling.  Van  Buskirk**^  has  made  a  thorough 
study  of  the  climate  of  Korea  with  reference  to  its  effect  on 
foreigners.  The  practical  applications  of  these  studies,"  and 
many  others  which  should  be  undertaken,  should  be  placed  in 
the  hands  of  all  missionaries,  either  directly  or  through  a 
column  in  the  Chinese  Recorder, 

For  large  undertakings,  such  as  the  building  of  schools, 
the  institution  of  more  complete  sanitary  measures  in  cities 
and  at  so-called  health  resorts  (which  are  often  the  play- 
ground for  epidemics),  for  effective  protest  to  operators  of 


114     The  Health   of  Missionary  Families  in   China 

river  steamers,  etc.,  there  should  be  active  co-operation  be- 
tween the  missionary  body  and  the  rapidly  growing  group  of 
non-missionary  foreigners  doing  business  in  China. 

THE    EXTRAVAGANCE    OF    SICKNESS 

Back  of  mission  boards  lies  the  contributing,  church,  a 
church  which  seems  sometimes  to  give  best  when  its  mission- 
aries are  represented  as  suffering  most  of  physical  privation 
and  hardship.  In  order  that  the  boards  may  not  be  hampered 
in  adopting  "energetic,  co-operative,  comprehensive"  health 
policies,  there  is  need  for  an  increased  interest  of  the  church 
in  the  physical  welfare  of  missionaries  and  a  realization  of 
the  fact  that  maintenance  of  good  health  is  good  economy. 
For  this  reason  the  facts  of  this  study  are  not  kept  secret. 
Sickness  anywhere  is  expensive,  but  w^lien  the  sick  one  or  his 
successor  has  to  be  sent  10,000  miles,  it  is  an  extravagance. 
Things  that  make  for  health  are  not  luxuries,  but  money- 
saving  necessities. 

Modem  preventive  medicine  has  shown  that,  to  a  large 
extent,  good  health  is  purchasable.  Pittsburgh,^"  for  example, 
has  bought  more  than  300  lives  a  year  (formerly  taken  by 
typhoid  fever)  by  the  erection  of  a  $5,700,000  water  filter 
plant,  and  considers  the  purchase  a  bargain.  No  man  of  busi- 
ness would  spend  several  thousand  dollars  for  an  automobile 
and  then  let  it  go  to  the  junk  pile  for  lack  of  oil  or  for  neglect 
of  necessary  repairs.  Neither  would  the  contributor  to  mis- 
sions, if  the  matter  were  presented  to  him,  after  spending  a 
like  amount  for  sending  a  family  to  the  field,  object  to  the 
additional  expenditures  necessary  to  keep  it  in  health.  Vac- 
cine, wire  screening,  proper  medical  advice,  sanitary  dwell- 
ings, adequate  salaries,  vacations,  health  surveys,  etc.,  are  ex- 
pensive, but  not  so  expensive  as  sickness. 

It  has  been  figured  by  a  leading  statistician  that  the  periodic  exami- 
nation of  any  group  will  save  at  least  three  lives  per  thousand  per  annum, 
apart  from  the  dividends  in  increased  health.  If  this  is  true,  20  lives  a 
year  would  be  saved  to  the  missionary  force  in  China  through  this  one 
means.  At  the  usual  valuation  of  life,  this  would  save  at  least  $100,000 
a  year.  Since  some  of  the  boards  already  provide  for  regular  examinations 
(usually  only  at  the  time  of  furlough)  a  yearly  examination  would  not  reduce 
mortality  to  the  extent  named.  However,  it  should  save  $40,00n-$50,000, 
which  would  more  than  pay  the  expenses  of  a  dozen  additional  doctors  to 
conduct  the  examinations. 

The  purchase  of  health,  like  any  commodity  of  value, 
requires  careful  planning  and  the  aid  of  expert  advice.  The 
employment  of  a  staff  of  experts  such  as  has  been  suggested, 
would,  in  the  course  of  a  few  years,  save  hundreds  of  thou- 
sands of  dollars  now  wasted  in  poor  health  and  death. 


Some  Factors  in  Prevention   of  Disease  115 

Such  intelligent,  scientific  supervision  of  health  would 
increase  morale  and  make  it  easier  to  secure  recruits  among 
those  who  hesitate  to  expose  children  to  the  hazards  of  mis- 
sionary life.  A  missionary  is  not  afraid  of  death,  but  he 
would  rather  be  killed  in  battle,  than  tamely  fall  a  victim  of 
some  easily  preventable  sickness. 


SUMMARY 

This  is  a  study  of  facts  concerning  the  health  of  60%  of 
the  missionary  families  in  China.  Facts  are  tabulated  con- 
cerning 1,300  marriages,  and  4,831  persons  (1,577  adults  and 
3,254  children).  Facts  concerning  451  deaths  of  children,  59 
stillbirths  and  416  miscarriages  and  nearly  7,500  cases  of  sick- 
ness are  analyzed.  The  study  represents  a  total  of  more  than 
35,000  years  spent  in  China.  The  principal  facts  which  have 
come  to  light  are  as  follows : 

1.  Each  marriage  has  resulted  in  an  average  of  2.5  chil- 
dren, which  is  at  least  20%  more  than  that  for  the  average 
college  graduate  or  college  teacher  in  the  United  States.  Only 
13%  of  the  marriages  are  childless,  against  31%  among  Amer- 
ican college  women. 

2.  American  societies  average  2.33  children  per  marriage, 
English  and  Canadian,  2.63 ;  European,  2.88. 

3.  Three-fourths  of  the  families  have  no  children  dead. 

4.  The  children  average  SV2  years  in  age,  67%  of  their 
time  has  been  spent  in  China.  Ten  per  cent  less  time  has  been 
spent  in  Southern  than  in  other  provinces. 

5.  Mortality  amog  these  children  is  considerably  less  than 
half  what  it  is  among  Chinese  children,  but  IV2  times  greater 
than  among  children  of  missionaries  in  Japan.  (139  in  China 
to  95  in  Japan.)  The  excess  for  China  occurs  in  the  group 
of  children  aged  1  to  5  years. 

6.  Infant  mortality  is  only  60.  The  rate  for  the  first  six 
months  is  extremely  low,  lower  than  among  professional  men 
in  England,  but  during  the  last  six  months  it  is  two  to  three 
times  as  high,  due  largely  to  dysentery  and  other  intestinal 
infections,  which  are,  in  turn,  probably  due  to  lack  of  breast 
feeding. 

7.  Death  rates  of  children  from  the  second  to  the  fifth 
years  are  three  times  as  high  as  in  countiy  districts  in  Eng- 
land having  about  the  same  infant  death  rate. 


116     The  Health   of  Missionary  Families  in   China 

8.  Mortality,  in  general,  decreases  from  north  to  south. 
It  is  more  than  twice  as  high  in  North  China  as  in  South 
China.  This  is  due  both  to  the  greater  prevalence  of  the  infec- 
tious diseases,  and  to  the  larger  percentage  of  deaths  among 
those  taken  sick.  Intestinal  and  respiratoiy  infections  and 
smallpox  are  most  markedly  deadly  in  the  north.  Consider- 
ing the  societies  individually,  most  of  them  show  higher  mor- 
tality rates  in  the  north  than  in  the  south. 

9.  Mortality  varies  markedly  in  the  various  societies,  the 
highest  having  three  times  the  rate  of  the  lowest.  High  rates 
are  due  to  the  general  infections  and  intestinal  diseases.  Kates 
are  higher  in  societies  having  the  larger  number  of  children 
per  family. 

10.  Mortality  is  higher  in  the  societies  reporting  less  than 
20  children. 

11.  Mortality  is  equally  low  in  American  and  English 
societies,  the  high  rates  found  in  European  societies  are  due 
to  dysentery,  diarrhoea,  and  smallpox,  each  of  which  is  two  to 
four  times  as  deadly  as  in  American  or  English  societies. 

12.  Mortality  is  lowest  when  a  parent  is  born  in  China, 
highest  when  parents  are  born  in  Europe.  Of  the  latter  class, 
15%  of  the  deaths  are  due  to  smallpox. 

13.  Mortality  is  lower  in  families  where  parents  have  had 
medical  training,  largely  because  of  the  decrease  in  general 
infectious  diseases.  Training  of  the  mother  is  of  more  impor- 
tance than  training  of  the  father,  as  shown  by  decrease  in  in- 
testinal and  general  infections.  This  points  to  the  advantage 
of  education  of  the  mother  in  home  sanitation. 

14.  Mortality  is,  in  general,  lower  in  societies  having  the 
larger  ratio  of  doctors  to  missionary  force. 

15.  The  decrease  of  mortality  in  the  more  recent  years 
has  probably  not  exceeded  the  rate  of  decrease  in  England 
and  America.  Infections  other  than  dysentery  have  decreased 
most. 

16.  Mortality  has  decreased  for  successive  children 
through  the  fifth  child,  after  which  it  has  increased.  Smallpox 
is  six  times  as  deadly  among  children  bom  sixth  or  later, 
while  dysentery  is  less  deadly. 

17.  Large  families  have  a  considerabl}^  higher  rate  than 
small  families.  This  is  due  to  the  general  infectious  diseases, 
including  smallpox,  and  diarrhoea.  This  points  to  poor  quar- 
antine within  the  home. 


Some  Factors  in  Prevention   of  Disease  117 

18.  Mortality  rates  are  slightly  lower  for  children  born 
outside  of  China  than  for  those  born  within.  They  are  lower 
in  the  groups  of  societies  in  which  parents  have  spent  the 
largest  percentage  of  time  off  the  field. 

19.  Dysentery  has  caused  19%  of  all  deaths,  diarrhoea 
12%,  respiratory  infections  13%,  diphtheria  6%,  conditions 
^^sociated  with  birth  10%,  smallpox  nearly  5%;  88%  of 
deaths  have  occurred  before  the  age  of  seven. 

20.  Compared  with  the  United  States  and  England,  dys- 
entery, smallpox  and  injury  at  birth  take  a  large  toll  for  the 
first  five  years.  After  five  years,  scarlet  fever  is  relatively 
deadly.  The  early  appearance  of  typhoid  (7.5%  of  deaths 
from  5-9)  points  to  the  need  of  early  inoculation. 

21.  Less  than  7%  of  deaths  occurred  in  the  homeland; 
33%  of  the  time  was  spent  there. 

22.  Of  the  children  dying  aged  five  years  or  over  in  four 
groups  of  societies,  one-third  were  killed  in  the  late  war. 

In  general  the  various  tabulations  show  that  infant  mor- 
tality is  much  less  variable  than  mortality  of  childhood,  also 
that  rates  due  to  birth,  development  and  nutrition  vary  less 
than  those  due  to  infections.  Since  the  diseases  whose  rates 
fluctuate  most  are  most  preventable,  effort  directed  against 
the  infectious  (bacterial)  diseases  of  early  childhood  will  yield 
the  largest  returns. 

23.  Sickness  rates,  in  contrast  with  mortality  rates,  are 
highest  in  Central  and  South  China,  due  to  increase  of  malaria 
and  intestinal  parasites.  In  South  China  also,  fewer  children 
have  robust  health.  Dysentery  in  relation  to  years  of  resi- 
dence is  less  prevalent  in  the  coast  and  Yangtse  valley  pro- 
vinces. The  absolute  number  of  cases  is  greater  in  these  sec- 
tions because  the  number  of  missionaries  is  greater. 

24.  Scarlet  fever,  measles,  mumps,  chicken  pox  and 
whooping  cough  are  contracted  relatively  more  frequently 
outside  of  China  than  are  the  less  highly  infectious  diseases. 

25.  The  largest  number  of  dysentery  infections  occur  dur- 
ing the  second  and  third  years,  of  diarrhoea  during  the  first 
and  second.    The  younger  the  child,  the  higher  the  mortality. 

26.  Miscarriages  number  13.4%  of  live  births,  the  rate 
being  highest  in  South  China.  The  number  of  miscarriages 
per  family  is  also  highest  in  the  south,  24%  of  the  wives  have 
had  one  miscarriage  or  more,  a  comparatively  high  rate.  87% 
of  miscarriages  occurred  in  China,  against  82%  of  married 


118     The  Health   of  Missionary  Families  in   China 

years  spent  there.  Travel  and  overwork  caused  a  larger  pro- 
portion of  miscarriages  at  home  than  it  did  in  China.  Over- 
work, disability,  nervousness,  etc.,  are  thought  to  be  respon- 
sible for  one-half  of  the  miscarriages. 

27.  Stillbirths  were  1.84%  of  living  births,  a  low  rate, 
probably  largely  due  to  the  absence  of  syphilis  among  mis- 
sionaries. 

28.  Missionaries  have  been  married  an  average  of  11.6 
years.  The  average  adult  life  on  the  field  is  20%  less  in  South 
China  than  in  North  China.  55%  have  been  in  China  10  years 
or  less. 

29.  Most  numerous  diseases  among  adults  in  China  in 
order  of  frequency  are :  malaria,  dysentery,  typhoid,  nervous 
breakdown,  influenza,  diarrhoea,  spine,  appendicitis  opera- 
tions, smallpox,  typhus  fever,  tuberculosis.  Central  and  South 
China  show  larger  numbers  of  illnesses  than  North  China. 

30.  Cases  of  malaria  and  dysentery  are  much  more  numer- 
ous among  husbands  than  among  wives.  In  the  case  of  sprue, 
the  reverse  is  true. 

31.  Forty-six  per  cent  of  the  infections  are  contracted 
within  the  first  three  years  after  arrival  in  China. 

32.  More  than  half  (53%)  of  adults  have  had  serious 
illness  in  China.  Fewer  have  been  sick  in  North  China  than 
in  Central  and  South  China.  The  rate  is  the  same  for  hus- 
bands and  wives. 

33.  Only  20%  of  wives  and  30%  of  husbands  say  they 
have  been  in  robust  health.  For  wives,  the  proportion  is  con- 
stant for  the  sections  of  China.  For  husbands,  33%  in  the 
north  have  had  robust  health,  against  17%  in  the  south.  This 
is  perhaps  due  to  the  especially  high  incidence  of  malaria 
among  husbands  in  the  south. 

34.  The  proportion  having  robust  health  in  various  soci- 
eties varies  widely,  but  in  general,  the  societies  with  high  mor- 
tality rate  among  children  have  a  low  percentage  of  robust 
health  among  parents.  In  general,  though  mortality  among 
children  is  much  higher  in  the  north,  the  morbidity  rate 
among  adults  and  children  is  less,  miscarriages  fewer,  the 
general  health  better,  and  the  residence  in  China  longer  for 
those  who  live  in  North  China.  This  is  because  the  diseases 
of  North  China  (dysentery,  pneumonia,  diphtheria,  scarlet 
fever,  smallpox)  cause  death.  Those  of  South  China  (mala- 
ria, intestinal  parasites)  and  the  climate,  cause  invalidism. 


Some  Factors  in  Prevention  of  Disease  119 

35.  Three-fourths  of  the  deaths  of  children  are  due  to 
infectious  diseases,  for  which  the  ratio  of  preventability  is 
high.  Given  knowledge  and  command  of  preventive  measures, 
it  is  possible  to  save  200  of  the  300  deaths  from  the  infectious 
diseases  here  recorded. 

36.  Among  adults  and  children  here  reported  (about  41% 
of  the  total  missionary  body)  dysentery  has  caused  808  cases 
of  sickness  and  84  deaths. 

37.  If  the  typhoid  fever  rate  were  reduced  to  that  prevail- 
ing in  the  United  States  army  since  the  introduction  of  com- 
pulsory inoculation,  in  ten  years  on  the  field  there  would  be 
a  saving  of  56  lives  and  $336,000.  Typhoid  contracted  by 
adults  in  China  outnumbers  cases  contracted  by  them  at 
home  12  to  1. 

38.  One  hundred  and  eleven  cases  of  smallpox,  with  28 
deaths,  are  recorded  among  children  and  adults,  a  rate  95 
times  that  for  the  general  population  of  the  United  States. 
No  deaths  have  occurred  in  families  in  which  parents  have 
had  medical  training.  In  51  cases  in  which  the  record  of  vac- 
cinations is  known,  six  cases  occurred  in  individuals  who  had 
''takes"  within  five  years,  pointing  to  the  need  of  more  fre- 
quent vaccination.  Only  one  death  occurred  in  a  person  who 
had  been  vaccinated.  Cases  of  smallpox  contracted  by  adults 
in  China  outnumber  cases  contracted  at  home  30  to  1.  Among 
the  children,  no  case  contracted  outside  of  China  was  reported. 

For  some  of  these  conclusions,  modifying  sojrces  of 
error,  which  have  been  named,  should  be  noted.  A  closer  com- 
parison of  facts  will  be  possible  when  statistics  now  being  col- 
lected among  missionaries  in  Japan  and  church  members  in 
America  have  been  tabulated. 

In  certain  sections  of  China,  or  among  certain  groups, 
children  of  missionaries  have  as  good  a  chance  for  life  and 
health  as  children  at  home.  Taking  the  missionary  body  as 
a  whole,  however,  there  has  been  an  excessive  loss  of  life 
among  both  children  and  adults.  Much  of  this  loss  may  in 
future  be  prevented.  For  such  prevention,  both  intelligent 
vigilance  on  the  part  of  the  individual  and  a  larger  co-opera- 
tive health  program  on  the  part  of  the  churches  is  needed. 
Increased  expenditure,  if  based  on  facts,  would  result  in  great 
money-saving,  and  would  aid  in  bringing  nearer  the  longed- 
for  coming  of  the  New  Day  to  China. 


120     The  Health   of  Missionary  Families  in   China 


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32.  Mortality  Statistics,  U.  S.  Bureau  of  the  Census.     1909. 

33.  Musser  and  Kelly.     Practical  Treatment.     Vol.  IV. 

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36.  Wilson,  S.  D.  A  Study  of  Chinese  Foods.  China  Medical  Journal,  Sept., 
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